Inspection·May 28, 2025

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to maintain an effective pest control program. This affected three residents (#13, #22, and #30) of four residents reviewed and had the potential to affect 45 residents. The facility census was 73. Residents Affected - Few Findings include: 1. Record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including muscle weakness, chronic kidney disease, and anxiety disorder. Review of a minimum data set (MDS) completed 05/02/25 revealed Resident #13's cognition remained intact, and she had other behaviors one to three days during the review period. Interview on 05/27/25 at 12:36 P.M. with Certified Nursing Assistant (CNA) #115 revealed Resident #13's room is really bad with gnats. CNA #115 stated she once opened the microwave in the kitchenette and gnats flew out at her. Interview on 05/27/25 at 1:00 P.M. with Resident #13 stated she would like to get rid of the gnats because they are everywhere and there isn't even food in my room. Resident #13 stated she was unable to lay in bed without gnats flying at her face. Resident #13 stated even in the dining room she had a hard time eating because she had to swat them away. Observation on 05/27/25 at 1:04 P.M. of Resident #13's room revealed when walking in the room, the doorway was next to the sink. While walking by the sink, three gnats flew into view. There were also gnats flying around Resident #13's bed. Resident #13's roommate was asleep in her recliner with her bedside table over her lap. She had two cups on the table in front of her and three gnats were on her cups. Observation on 05/27/25 at 2:04 P.M. with CNA #115 revealed a cart with three discarded meal trays in the hallway next too room [ROOM NUMBER] which had about 10 gnats swarming it. CNA #115 confirmed the observation. 2. Record review revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including monoplegia of lower limb following cerebral infarction, dementia, and depression. Review of a MDS completed 04/02/25 revealed Resident #22's cognition is mildly impaired and she had no behaviors. (continued on next page) 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 REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 366001 Printed: 05/15/2026 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 366001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmar Place Rehab & Extended Care 401 Harmar Street Marietta, OH 45750 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)