Harmar Village Health & Rehab Center

Observation on 3/30/26, at 11:22 a.m.

Resident R56 was in the main dining room sitting in a wheelchair.

The seat and cushion of the wheelchair were completely covered in dried foods, sticky substance, and dark grime.

Interview on 3/30/26, at 11:23 a.m.

Respiratory Therapist Employee E3 confirmed Resident R56 was in the main dining room sitting in a wheelchair.

The seat and cushion of the wheelchair were completely covered in dried foods, sticky substance, and dark grime.

Review of the face sheet indicated Resident R26 admitted to the facility on [DATE].

Observation on 3/30/26, at 11:28 a.m. a white pipe cover was on the floor under Resident R26's room sink.

Interview on 3/30/26, at 11:29 a.m.

Licensed Practical Nurse (LPN) Employee E1 confirmed a white pipe cover was on the floor under Resident R26's room sink.

Review of the face sheet indicated Resident R59 admitted to the facility on [DATE].

Observation on 3/30/26, at 12:10 p.m.

Resident R59's window blinds had three leaves missing and one lying on the floor under the air condition unit in the room.

Interview on 3/30/26, at 12:11 p.m. LPN Employee E4 confirmed Resident R59's window blinds had three leaves missing and one lying on the floor under the air condition unit in the room.

Observation and tour with Administrator Employee E5 on 3/31/26, at 9:54 a.m. the entire width of Resident R59's window was draped with thick cobwebs behind the blind.

Interview on 3/31/26, at 9:55 a.m.

Administrator Employee E5 confirmed the entire width of Resident R59's window was draped with thick cobwebs behind the blind.

Observation on 3/31/26, at 9:40 a.m. the side-by-side elevators located next to the dietary entrance each had plastic bumpers to the lower walls and each of the bumpers had sharp shards of broken plastic exposed.

Interview on 3/31/26, at 9:41 a.m.

Maintenance Employee E6 confirmed the side-by-side elevators located next to the dietary entrance each had plastic bumpers to the lower walls and each of the bumpers had sharp shards of broken plastic exposed.

Maintenance Employee E6 indicated carts bang into the bumpers causing the damage.

Interview on 3/31/26, at 3:00 p.m.

Administrator Employee E5 confirmed the facility failed to provide a clean, safe, comfortable, and homelike environment for one of five resident wheelchairs (Resident R56), two of five resident rooms (Resident R26, and Resident R59), and two of three resident elevators (beside dietary entrance). 28 Pa Code: 201.18 (e)(2) Management.28 Pa Code: 201.29 (a) Resident Rights.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

396048 04/03/2026

Harmar Village Health & Rehab Center 715 Freeport Road Cheswick, PA 15024

Review of Resident R122's admission record indicated he was admitted to facility 3/27/2026.

Review of Resident R122's Nursing admission Observation report indicated diagnoses to include paraplegia (form of paralysis that primarily affects the lower half of the body), depression, anxiety disorder, and bipolar disorder (mental health condition characterized by significant mood swings, including manic and depressive episodes).

Review of Resident R122's clinical record revealed physician orders for the following psychotropic medications and failed to have a diagnosis for use of each medication:Buspirone (Buspar, antianxiety medication) tablet; 10 mg (milligrams); amount 2 tab; oral three times a dayEscitalopram oxalate (Lexapro, antidepressant medication) tablet; 20 mg; amount 1 tab; oral once a dayMirtazapine (Remeron, antidepressant medication)) tablet; 15 mg; amount 1 tab; oral at bedtimeQuetiapine (Seroquel, antipsychotic medication) tablet; 100 mg; amount 1 tablet; oral at bedtimeQuetiapine tablet; 25 mg; amount 1 tablet; oral once a day Review of Resident R122's clinical record failed to indicate any documented non-pharmacological interventions or effectiveness of pharmacological interventions; clinical record also failed to indicate evidence that the facility had implement side effect or behavior monitoring for psychotropic medication use.

During an interview of 4/1/26, at 2:23 p.m., Registered Nurse Assessment Coordinator (RNAC) Employee E17 confirmed that Resident R122's psychotropic medication orders failed to indicate a diagnosis for usage and that the clinical record failed to contain documented evidence identifying interventions, medication effectiveness, and monitoring of side effects and behaviors.

During an interview on 4/2/26, at 12:30 p.m., Administrator Employee E5 and Director of Nursing (DON) confirmed that the facility failed to make certain resident medication regimens were free from potentially unnecessary psychotropic medications without adequate indications for use for one of five residents (Resident R122). 28 Pa Code: 201.14(a) Responsibility of licensee.28 Pa.

Code 211.5(f) Medical records.28 Pa.

Code 211.12(d)(1)(3)(5) Nursing services.

396048 04/03/2026

Harmar Village Health & Rehab Center 715 Freeport Road Cheswick, PA 15024

The facility failed to implement interventions in the

constipation.

Review of Resident R65's physician order dated 3/2/26, indicated to administer 17 gram

3/2/26, indicated to administer 8.6 mg Senna (used to treat constipation and promote bowel movements) twice a day as needed. if no bowel movement by Day 2 in the morning for constipation.

Review of Resident R65's Bowel Documentation revealed no evidence of a bowel movement on 3/25/26, 3/26/26, 3/27/26 (a total of three days).

Review of Resident R65's March 2026 Medication Administration Record revealed the resident did not receive Miralax or Senna as needed on 3/27/26, as ordered.

Review of Resident R65's clinical record failed to include evidence the physician was notified the resident failed to have a bowel movement after three days.

During an interview on 3/30/26, at 9:53 a.m.

Resident R65 revealed a concern related to constipation.

Resident R65 stated her bum hole was so sore.

Resident R65 indicated she couldn't poop, it was hard as a rock and her stomach hurt so bad.

During an interview on 3/31/26, at 12:51 p.m. the Assistant Director of Nursing (ADON), Employee E10 confirmed the facility failed to implement the bowel protocol ordered for Resident R31 and R65.

During an interview on 3/31/26, at 1:04 p.m. the Nursing Home Administrator confirmed the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and follow physician orders for two of six residents (Resident R31 and R65). 28 Pa.

Code: 201.14(a) Responsibility of licensee.28 Pa.

Code: 211.10(d) Resident care policies.28 Pa.

Code: 211.12(d)(1)(5) Nursing services.

396048 04/03/2026

Harmar Village Health & Rehab Center 715 Freeport Road Cheswick, PA 15024

During an interview on 3/31/26, at 2:54 p.m.

Occupational Therapist (OT) was asked did Resident CR42 ' s have sling when you first saw him? Resident CR42 was non-weight bearing and he had a sling on.

During an interview on 4/1/26, at 9:24 a.m.

Licensed Practical Nurse (LPN) Employee E1 was asked if he had resident with sling and does non-weight bearing mean to use a sling? : yes. one resident is Resident R124. He has a sling on his right arm. We check the skin by carefully taking off the sling and looking. I would imagine the record has skin check order.

During an interview on 4/1/26, at 1:00 p.m.

Wound consultant Employee E16 was asked what are the expectations for nursing to review skin when resident has sling and stated: I know when he first was admitted , he had a sling. I'm trying to pull up his record. He had a sling on when initially admitted .

The expectation to check under the sling include removing the sling, looking up around the neck, look at all the parts of the skin that you cannot see with the sling on. I worry most about where the straps are under the neck.

During an interview on 4/1/26, at 1:29 p.m.

Regional Risk Employee E9, Nursing Home Administrator (NHA) and Administrator Employee E5 information was disseminated that the facility failed to make certain residents were provided necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure ulcers for Closed Resident Record CR42. 28 Pa.

Code: 201.29(a) Resident Rights. 28 Pa.

Code 211.10(c)(d) Resident Care Policies. 28 Pa.

Code 211.12(d)(1)(3)(5) Nursing services.

396048 04/03/2026

Harmar Village Health & Rehab Center 715 Freeport Road Cheswick, PA 15024

During an observation on 3/30/26, ay 9:44 a.m.

Resident R124 was observed wearing a right arm sling.

During an observation on 4/1/26, at 9:23 a.m.

Resident R124 was observed wearing a right arm sling.

During an interview on 4/1/26, at 9:24 a.m. LPN, Employee E1 confirmed Resident R124 did not have an order for a sling.

Review of Resident R124's clinical record failed to include a physician order or care plan for the resident's sling use.

During an interview on 4/1/26, at 10:05 a.m. the Nursing Home Administrator confirmed the facility failed to ensure a resident with limited mobility had a physician order for a sling for one of two residents (Residents R124). 28 Pa.

Code: 201.14(a) Responsibility of licensee. 28 Pa.

Code: 211.10(c)(d) Resident care policies. 28 Pa.

Code: 211.12(d)(1)(3)(5) Nursing services.

396048 04/03/2026

Harmar Village Health & Rehab Center 715 Freeport Road Cheswick, PA 15024

Review of Resident R72's admission record indicated he was originally admitted on [DATE] and re-admitted on [DATE].

Review of Resident R72's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 12/31/25, indicated he had diagnoses that included repeated falls, anxiety disorder (a medical condition creating a sense of acute fear, restlessness, and worry), benign prostatic hyperplasia with lower urinary tract (enlarged prostate impacting urine flow), and history of lung cancer.

Review of Resident R72's care plans dated 1/5/26, indicated that Resident R72 has history of obstructive uropathy, will remain free from catheter trauma, provide catheter care per routine, and change catheter as per physician order and as needed.

Review of Resident R72's clinical nurse notes dated 3/25/26, indicated Resident was swishing liquid in his mouth.

Asked resident if it was mouth wash.

Resident R72 shook his head no.

Resident R72 had a copious amount of mucus and spit, measuring 90cc's in cup.

Asked resident if he felt congested.

Resident R72 stated that he was.

Lungs were clear upon auscultation, but his voice sounded gurgled.

Resident R72 continued to gather saliva and mucus in his mouth and kept spitting.

Assessed vitals, all vitals were WNL (Within normal limits) aside from pulse ox.

Resident R72 was at 85% RA but had no complaints of SOB (shortness of breath).

Placed resident R72 on 2 Liters oxygen, Resident R72 was sating low 90's.

Upon rechecking, resident then went down to 81% on 2L. RN supervisor placed call to doctor and got order for 4L. RN Supervisor then got order to send resident out due to Resident R72 spitting copious amounts of mucus and saliva.

Resident R72 was sent with face-sheet, order and POLST.

Family is aware.

Review of Resident R72's clinical nurse notes dated 3/29/26, indicated Resident returned to facility via stretcher after being admitted to hospital.

Resident R72 was alert, pleasant and denied any pain.

Review of Resident R72's physician orders dated 10/27/25, indicated to provide Catheter Care.

Change supra-pubic catheter monthly and as needed.

Use 18french/ 10 cc Special Instructions: Document catheter18 fr (French) and 10 ml size inserted.

Order ends on 3/25/26.

Review of Resident R72's physician orders and re-admission orders dated 3/30/26, did not include an order for Catheter care, catheter sizing, physician orders when to change the catheter or orders to irrigate Resident R72's catheter.

During observations on 3/30/26, at 11:31 a.m.

Resident R72 was observed in bed, his catheter in place via leg bag.

During observations on 3/30/26, at 2:21 p.m.

Resident R72 was observed in bed after lunch, his catheter in place via leg bag.

During an interview on 3/30/26, at 2:21 p.m.

Nurse aide Employee E18 stated: he has a leg bag.

During observations on 3/31/26, at 9:24 a.m.

Resident R72 was observed in bed, his catheter in place via leg bag.

During an interview on 3/31/26, at 9:34 a.m. the Director of Nursing (DON) confirmed that the facility failed to obtain appropriate physician orders for Resident R72's urinary catheter as required. 28 Pa.

Code: 211.5(f) Clinical records 28 Pa.

Code: 211.12(c)(d)(1)(3)(5) Nursing

396048 04/03/2026

Harmar Village Health & Rehab Center 715 Freeport Road Cheswick, PA 15024

Review of facility policy Diet Orders dated 8/15/25, indicated the facility will ensure residents are provided meals as ordered by their healthcare provider.

Diet orders will follow the facility formulary or an individualized diet as written/approved by the Registered Dietitian Nutritionist.

The Food and Nutrition Services Manager will utilize a tray card identification system to ensure that each resident receives his or her diet as ordered, and that the diet in the medical record reflects the diet in the tray card system.

Review of facility policy Comprehensive Care Planning dated 8/15/25, indicated an interdisciplinary plan of care will be established and updated as indicated for every resident in accordance with state and federal regulatory requirements.

The care plan is reviewed on an ongoing basis and revised as indicated by the resident's needs, wishes, or a change in condition.

Review of the admission record indicated that Resident R13 was admitted to the facility on [DATE].

Review of Resident R13's Minimum Data Set (MDS- a periodic assessment of care needs) dated 2/24/26, indicated the diagnoses of diabetes mellitus (chronic condition that occurs when the body cannot properly use blood sugar (glucose), leading to high blood sugar levels) , high blood pressure, and dementia (syndrome characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities).

Review of Medical Nutritional Therapy assessment dated [DATE], indicated that Resident R13's diet as ordered is Mechanical soft, LCS (Low Concentrated Sweets).

Review of clinical progress note dated 2/24/26, indicated Resident R13 appears to be an appropriate candidate to return to baseline diet.

Recommend diet advancement to regular solids/thin liquids.

Review of Resident R13's physician order dated 2/18/26, revealed LCS, Mech soft diet order; discontinued 2/24/26.

Review of Resident R13's current physician order dated 2/24/26, revealed Regular diet order.

Review of facility provided EMR (Electronic Medical Record) Resident Diet Order Report indicated Resident R13 was ordered a Regular diet.

Review of facility provided Consistency Census Report from Dietary Departments tray card system indicated Resident R13's diet order as Regular.

Review of Resident R13's current nutrition status plan of care, updated 2/19/26, revealed an approach/intervention to Provide diet per order: LCS, Mech soft texture diet.

During an interview on 4/3/26, at 9:30 a.m., Resident Nurse Assessment Coordinator (RNAC) Employee E17 confirmed that Resident R13's nutrition status care plan was not updated to reflect current diet order Regular.

Review of clinical progress note dated 3/25/26, by Registered Dietitian (RD) Employee E21 indicated that Resident R13 is currently ordered a Regular diet.

Further review of the clinical record failed to indicate documentation providing rationale for the discontinuation of therapeutic diet restriction LCS by the Registered Dietitian or physician.

During an interview on 4/3/26, at 10:17 a.m., Regional Risk Employee E9 confirmed Resident R13's clinical record failed to provide rationale for discontinuing LCS therapeutic diet restriction.

During an interview on 4/3/26, at 12:30 p.m., Administrator Employee E5 and Director of Nursing (DON) confirmed that the facility failed to update an individualized care plan to address the resident's specific nutritional concerns and preferences and failed to address discontinued resident specific interventions for one of three residents (Resident R13). 28 Pa.

Code: 201.18(b)(1)(e)(1) Management.28 Pa.

Code: 211.12(d)(3)(5)Nursing services.

396048 04/03/2026

Harmar Village Health & Rehab Center 715 Freeport Road Cheswick, PA 15024

Review of Resident R118's care plan dated 3/13/26, indicated to provide tube feed and flush per order.

Review of Resident 118's physician order dated 3/16/26, revealed an order for Enteral: Pump Feed Set Up Special Instructions: Provide Isosource 1.5 at 60ml/hr x 22 hours.

Hang at 11 AM.

Take down at 9 AM or when 1320 ml total volume has been infused Review of Resident 118's physician order dated 3/16/26, indicated to give 150ml free water flush every four hours, six times a day.

Observation on 3/30/26, at 10:30 a.m.

Resident R118's 1.5 Isosource bottle and 1000 ml water flush bag were undated.

Interview on 3/30/26, at 10:34 a.m. the Director of Nursing confirmed there was no date on Resident R118 tube feed or water flush.

Observation on 3/31/26, at 11:35 a.m. revealed the water flush bag was not dated.

Interview on 3/31/26, at 11:39 a.m.

Licensed Practical Nurse Employee E14 confirmed Resident R118's water flush bag was undated.

Interview with the Director of Nursing and Administrator, Employee E5 on 4/3/26, at approximately 12:30 p.m. confirmed the facility failed to ensure a resident receiving enteral feeding received appropriate care and services for one of two resident reviewed (Resident 118). 28 Pa.

Code 211.12(d)(1)(3)(5) Nursing services

396048 04/03/2026

Harmar Village Health & Rehab Center 715 Freeport Road Cheswick, PA 15024

Review of the face sheet indicated Resident R101 admitted to the facility on [DATE].

Review of Resident R101's MDS dated [DATE], indicated diagnoses of heart failure (heart doesn't pump blood as well as it should), high blood pressure, and depression.

Review of Resident R101's physician order 1/12/26, indicated oxygen: clean oxygen concentrator and filter, change tubing weekly.

Wipe down concentrator, remove filter, clean, and airdry.

Change tubingonce a week.

Observation on 3/30/26, at 11:30 a.m.

Resident R101 was sitting in a wheelchair connected to a concentrator by nasal cannula.

The tubing was not dated as required and the concentrator and the external filter were dusty with a layer of fuzz like debris.

Interview on 3/30/26, at 11:32 a.m.

Respiratory Therapist Employee E3 confirmed Resident R101 was sitting in a wheelchair connected to a concentrator by nasal cannula.

The tubing was not dated as required and the concentrator and the external filter were dusty with a layer of fuzz like debris.

Interview on 3/30/26, at 3:00 p.m. the Director of Nursing confirmed the facility failed to provide appropriate respiratory care and maintain oxygen equipment for three of three residents (Residents R56, R65, and R101). 28 Pa.

Code 211.12(d)(1)(5) Nursing services

396048 04/03/2026

Harmar Village Health & Rehab Center 715 Freeport Road Cheswick, PA 15024

During an interview on 4/1/26, at 9:23 a.m. LPN, Employee E14 confirmed she failed to administer Resident R61's fluticasone propionate 50 MCG/ACTUAT Metered Dose Nasal Spray [Flonase] and olopatadine 1 MG/ML Ophthalmic Solution due to the medications not being available. LPN, Employee 14 confirmed she failed to prepare and administer Resident R61's Ingreeza by sprinkling the contents of capsule in pudding.

During an interview on 4/1/26, at 9:25 a.m. the Assistant Director of Nursing, Employee E22confirmed LPN, Employee E14 failed to appropriately administer Ingrezza medication as crushed, resulting in a significant medication error.

During medication administration observations, there were three errors and 36 opportunities, resulting in a medication error rate of 8.33% During a staff interview on 4/1/26, at 9:56 a.m. the Nursing Home Administrator (NHA) 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. 28 Pa.

Code 211.9(a)(1) Pharmacy services28 Pa.

Code 211.12(d)(1)(5) Nursing services

396048 04/03/2026

Harmar Village Health & Rehab Center 715 Freeport Road Cheswick, PA 15024

Review of the clinical record indicated Resident R61 was admitted to the facility on [DATE], with diagnoses of bipolar disorder, anxiety, and depression.

Review of Resident R61's care plan dated 11/18/25, indicated to finely crush the resident's pills.

Review of Resident R61's physician order dated 12/3/26, indicated to administer 40 milligram (mg) of Ingreeza (a prescription medication used to treat involuntary movements caused by tardive dyskinesia and chorea associated with Huntington's disease), one capsule, once a day for drug induced subacute dyskinesia.

Review of Resident R61's physician order dated 1/30/26, indicated the resident is to have medications crushed.

Review of Resident R61's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/25/26, indicated diagnoses were current.

Observation of medication administration on 4/1/26, at 8:56 a.m., Licensed Practical Nurse (LPN), Employee E14 was observed preparing to administer Resident R61 40 milligram (mg) Ingreeza softened in pudding. LPN, Employee E14 failed to ensure all medications were finely crushed. LPN, Employee E14 failed to safely administer Resident R61 medication.

During an interview on 4/1/26, at 9:23 a.m. LPN, Employee E14 confirmed she failed to administer Resident R61's Ingreeza by sprinkling the contents of capsule in pudding.

During an interview on 4/1/26, at 9:25 a.m. the Assistant Director of Nursing, Employee E22confirmed LPN, Employee E14 failed to appropriately administer Ingrezza medication as crushed, resulting in a significant medication error.

During a staff interview on 4/1/26, at 9:56 a.m. the Nursing Home Administrator (NHA) confirmed the facility failed to ensure that residents are free of significant medication errors for one of five residents reviewed (Resident R61). 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.

396048 04/03/2026

Harmar Village Health & Rehab Center 715 Freeport Road Cheswick, PA 15024

Observation on 3/30/26, at 12:02 p.m. indicated a treatment cart unlocked and unattended outside room [ROOM NUMBER].

Interview with Licensed Practical Nurse (LPN) Employee E4 on 3/30/26, at 12:04 p.m. confirmed a treatment cart unlocked and unattended outside room [ROOM NUMBER].

Observation on 4/1/26, at 8:57 a.m. the 2nd floor treatment cart was left unattended and unlocked in the South hallway.

Interview on 4/1/2026, at 8:58 a.m. LPN, Employee E19 confirmed the 2nd floor treatment cart was left unlocked and unattended in the hallway.

Observation of the East Hall Medication Cart on 4/1/26, at 9:07 a.m. indicated the following medications opened and not dated as required:-ipratropium bromide (breathing medication),-albuterol (breathing medication), and -fluticasone (nasal spray to treat allergy symptoms).

Interview on 4/1/26, at 9:08 a.m. LPN Employee E7 confirmed the medications were in the East Hall Medication Cart opened and not dated as required.

Observation on 3/30/26, at 9:05 a.m. indicated a treatment cart unlocked and unattended outside room [ROOM NUMBER].

Interview with Registered Nurse (RN) Employee E2 on 3/30/26, at 9:08 a.m. confirmed a treatment cart unlocked and unattended outside room [ROOM NUMBER].

Observation on 3/30/26, at 12:02 p.m. indicated a treatment cart unlocked and unattended outside room [ROOM NUMBER].

Interview with Licensed Practical Nurse (LPN) Employee E4 on 3/30/26, at 12:04 p.m. confirmed a treatment cart unlocked and unattended outside room [ROOM NUMBER].

Observation on 4/1/26, at 8:57 a.m. the 2nd floor treatment cart was left unattended and unlocked in the South hallway.

Interview on 4/1/2026, at 8:58 a.m. LPN, Employee E19 confirmed the 2nd floor treatment cart was left unlocked and unattended in the hallway.

Observation of the East Hall Medication Cart on 4/1/26, at 9:07 a.m. indicated the following medications opened and not dated as required:-ipratropium bromide (breathing medication),-albuterol (breathing medication), and -fluticasone (nasal spray to treat allergy symptoms).

Interview on 4/1/26, at 9:08 a.m. LPN Employee E7 confirmed the medications were in the East Hall Medication Cart opened and not dated as required.

Review of the face sheet indicated Resident R3 admitted to the facility on [DATE].

Observation on 3/30/26, at 9:10 a.m.

Resident R3 was observed out of bed in wheelchair. On the night stand a container of Vashe (hypochlorous acid wound cleanser) was noted along with a tube of zinc oxide.

Interview on 3/30/26, at 10:00 a.m.

Licensed Practical Nurse (LPN) Employee E1 confirmed the Vashe and zinc oxide were on the night stand.

Review of the face sheet indicated Resident R40 admitted to the facility on [DATE].

Observation on 3/30/26, at 9:16 a.m.

Resident R40 was sitting out of bed in a chair. On the bedside stand was a tube of triamcinolone cream.

Interview on 3/30/26, at 10:03 a.m. LPN Employee E1 confirmed the triamcinolone cream was on the night stand. 28 Pa.

Code: 211.10(c) Resident care policies.28 Pa.

Code: 211.12(d)(2)(3) Nursing services.

396048 04/03/2026

Harmar Village Health & Rehab Center 715 Freeport Road Cheswick, PA 15024

Review of the admission record indicated Resident R14 was admitted to the facility on [DATE].

Review of Resident R14's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/9/26, indicated diagnoses of heart failure (heart doesn't pump blood as well as it should), stroke (damage to the brain from an interruption of blood supply), and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy).

Review of Resident R14's progress notes dated 3/10/26, indicated social worker spoke with Resident R14's family who showed the social worker a picture of a lump that is in Resident R14's mouth on the gums.

Social worker discussed this with the care team.

Call to Dental vendor to schedule the dentist.

Interview on 3/31/26, at 10:09 a.m.

Social Worker Employee E8 indicated Resident R14 was seen by the dentist within the last two weeks.

Indicated on 3/16/26, the dentist vendor saw the resident and indicated the lump was just like an extra piece of bone and the dentist didn't believe that Resident R14 required any surgical intervention at this time.

That the lump is not interfering with anything.

The family feels Resident R14 is unable to chew well because of the lump and not able to wear dentures.

Request to review dental exam from 3/16/26, was provided by facility as it was not a part of the electronic health record, (not scanned in) which revealed date of service as 3/16/26.

The resident was not seen.

The resident was not on the team's final list, but the dentist talked to the family regarding the mandibular torus (slow-growing bony lumps on the inside of the lower jaw).

Resident would need to see an oral surgeon for surgical removal.

The family indicated that resident cannot be sedated so there was nothing the dentist could do.

The form was not signed by the doctor and left blank.

Interview with the Nursing Home Administrator on 4/1/26, at 2:00 p.m. confirmed that the dentist never saw or assessed Resident R14's mouth. 28 Pa.

Code 211.12(d)(1)(3)(5) Nursing services

396048 04/03/2026

Harmar Village Health & Rehab Center 715 Freeport Road Cheswick, PA 15024

Review of Quality Assurance and Performance Improvement (QAPI) sign in sheets and attendance records, failed to reveal documentation that quarterly meetings were conducted during Quarter Two 2025 and Quarter Three 2025.

During an interview on 4/1/26, at 9:08 a.m., the Administrator Employee E5 confirmed the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly as required. 28 Pa Code: 201.18(e)(1)(2)(3)(4) Management

396048 04/03/2026

Harmar Village Health & Rehab Center 715 Freeport Road Cheswick, PA 15024

Review of the facility policy Freezers and Refrigerators Policy dated 8/15/25, indicated monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures to be between 35 degrees and 41 degrees.

Review of the face sheet indicated Resident R12 admitted to the facility on [DATE].

Review of Resident R12's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/9/26, indicated the diagnoses of diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), stroke (damage to the brain from an interruption of blood supply), and seizure disorder (a person experiences abnormal behaviors, symptoms and sensations, sometimes including loss of consciousness) .

Section K0520 indicated feeding tube while a resident.

Review of Resident R12's physician order 1/11/26, indicated EBPs.

Observation on 3/30/26, at 10:00 a.m. indicated Licensed Practical Nurse (LPN) Employee E1 wearing gloves and hanging a new bag of tube feeding supplement via pump to the gastrostomy tube. LPN Employee E1 failed to put a gown on prior to an act of high contact activity.

Interview on 3/30/26, at 10:30 a.m. LPN Employee E1 confirmed they failed to wear a gown during high contact activity as required with EBP for Resident R12.

Review of the admission record indicated Resident R44 was admitted to the facility on [DATE].

Observation on 3/30/26, at 9:16 a.m.

Resident R44's personal refrigerator in the room had a temperature log on the outside.

The month and year were blank.

Fifteen of thirty days were blank.

Interview on 3/30/26, at 9:30 a.m.

Registered Nurse (RN) Employee E2 confirmed the temperature log for Resident R44's personal refrigerator had the month and year blank and that fifteen of thirty days were blank.

Interview on 3/30/26, at 3:00 p.m. the Director of Nursing confirmed the facility failed to ensure that Enhanced Barrier Precautions (EBP) were managed properly for one of three resident (Resident R12) and failed to properly monitor a resident's personal refrigerator temperature for one of two residents (Resident R44). 28 Pa.

Code 211.12(d)(1)(5) Nursing services.

396048 04/03/2026

Harmar Village Health & Rehab Center 715 Freeport Road Cheswick, PA 15024

Review of the face sheet indicated Resident R12 admitted to the facility on [DATE].

Review of Resident R12's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/9/26, indicated the diagnoses of diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), stroke (damage to the brain from an interruption of blood supply), and seizure disorder (a person experiences abnormal behaviors, symptoms and sensations, sometimes including loss of consciousness).

Review of Resident R12' immunization record indicated pneumococcal vaccine not due until 3/26/25.

Interview on 3/31/26, at 2:06 p.m.

Infection Preventionist Employee E10 indicated the facility could not provide documentation in the medical record that the immunization was assessed for Resident R12 on 3/26/25.

Review of the admission record indicated Resident R44 was admitted to the facility on [DATE].

Review of Resident R44's MDS dated [DATE], indicated the diagnoses of stroke, hemiplegia (paralysis of one side of the body), and Parkinson's Disease (disorder of the nervous system that results in tremors).

Review of Resident R44's immunization record indicated pneumococcal vaccine not due until 4/28/25.

Interview on 3/31/26, at 2:06 p.m.

Infection Preventionist Employee E10 indicated the facility could not provide documentation in the medical record that the immunization was assessed for Resident R44 on 4/28/25.

Interview on 3/31/26, at 3:00 p.m. the Regional Risk Employee E9 confirmed that the facility failed to make certain that pneumococcal vaccinations were tracked in the electronic health record (Residents R12, and R44). 28 Pa.

Code: 201.14(a) Responsibility of licensee.28 Pa.

Code 211.12(d)(1)(3) Nursing services.