Health inspection·February 27, 2026

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on review of facility policy and clinical records and staff interviews it was determined that the facility failed to make certain controlled substances were accounted for accurately for nine of twelve residents (Resident R1, R2, R3, R4, R5, R6, R7, R8, and R9).Findings include: The facility policy Medication Administration - General Guidelines last reviewed 2/1/26, indicated The individual who administers the medication dose records the administration on the resident's MAR (medication administration record) directly after the medication is given. Review of Resident R1's MAR (medication administration record) for February 2026, revealed an order for oxycodone 5mg (a narcotic pain medication used to treat moderate to severe pain) to be given every six hours as needed for pain. Ten administrations were documented on the MAR from 2/5/26, through 2/27/26. Review of Resident R1's Controlled Substance Record indicated that 15 additional doses of oxycodone were signed out without corresponding documentation of administration to 2/24/26, 2/25/26, and 2/26/26. Review of Resident R2's MAR for February 2026, revealed an order for Endocet 5-325 (a oxycodone and acetaminophen) half-tablet to be given every six hours as needed for moderate pain, and one tablet to be given every six hours for severe pain. Nineteen administrations were documented from 2/7/26, through 2/26/26. Review of Resident R2's Controlled Substance Record indicated that six additional doses of Endocet were signed out without corresponding documentation of R3's MAR for February 2026, revealed an order for Endocet 5-325 one tablet to be given every six hours for severe pain. Nineteen administrations were documented from 2/5/26, through 2/26/26. Review of Resident R3's Controlled Substance Record indicated that ten additional doses of Endocet were signed out without corresponding documentation of administration to the resident on 2/6/26, 2/10/26, 2/14/26, 2/16/26 , revealed an order for oxycodone 5mg to be given every four hours as needed for pain. Twelve administrations were documented on the MAR from 2/14/26, through 2/27/26. Review of Resident R4's Controlled Substance Record indicated that seven additional doses of oxycodone were signed out without corresponding documentation of administration to the resident on 2/14/26, 2/15/26, 2/16/26, 2/17/26, 2/23/26, 2/24/26, and 2/26/26. Review of Resident R5's MAR for February 2026, revealed an order for Endocet 5-325 (a oxycodone and acetaminophen) half-tablet to be given every six hours as needed for moderate pain, and one tablet to be given every six hours for severe pain. Four administrations were documented on the MAR from 2/17/26, through 2/27/26. Review of Resident R5's Controlled Substance Record indicated that six additional doses of Endocet were signed out without corresponding documentation of administration to the resident on 2/17/26, 2/20/26, 2/23/26, 2/24/26, 2/25/26, and 2/26/26. Review of Resident R6's MAR for February 2026, revealed an order for oxycodone 5mg to be given every four hours as needed for pain. Three administrations were documented on the MAR from 2/25/26, Page 1 of 2 395903 395903 02/27/2026 Harmony Hills Healthcare and Rehabilitation Center 194 Swinderman Road Wexford, PA 15090

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some through 2/27/26. Review of Resident R6's Controlled Substance Record indicated that three additional doses of oxycodone were signed out without corresponding documentation of administration to the resident Tramadol 50mg (an opioid pain medication used to treat moderate to severe pain) to be given every four hours as needed for pain. Four administrations were documented on the MAR from 2/21/26, through 2/27/26. Review of Resident R7's Controlled Substance Record indicated that three additional doses of Tramadol were signed out without corresponding documentation of administration to the resident on 2/22/26, 2/23/26, and 2/24/26. Review of Resident R8's MAR for February 2026, revealed an order for hydrocodone/ acetaminophen 5-325 (hydrocodone, and opiate narcotic pain medication and acetaminophen) to be given every eight hours for severe pain. Two administrations were documented on the MAR from 2/16/26, through 2/24/26. Review of Resident R5's Controlled Substance Record indicated that two additional doses of Endocet were signed out without corresponding documentation of administration to the resident on 2/16/26, and 2/20/26. Review of Resident R9's MAR for February 2026, revealed an order for oxycodone 5mg to be given every six hours as needed for pain. Eleven administrations were documented on the MAR from 2/15/26, through 2/26/26. Review of Resident R9's Controlled Substance Record indicated that three additional doses of oxycodone were signed out without corresponding documentation of administration to the resident on 2/16/26, 2/2/26, and 2/2/26. During an interview on 2/27/26, at approximately 2:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to make certain controlled substances were accounted for accurately for nine of twelve residents.28 Pa. Code: 211.9(a)(1)(j) Pharmacy services.28 Pa. Code: 211.12(d)(1)(5) Nursing services. 395903 Page 2 of 2