Health inspection·December 17, 2024

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, and staff interview, it was determined that the facility failed to complete admission activites evaluation for three of three residents as required. (Residents R1, R2 and R3) Findings include: During a review of clinical record indicated that Resident R3 was admitted [DATE]. During a review of clinical record clinical assessment summary indicated Resident R3 admission Activities Evaluation due date was 11/16/24, and it was not completed and overdue. During a review of clinical record indicated that Resident R1 was admitted [DATE]. During a review of clinical record clinical assessment summary indicated Resident R1 admission Activities Evaluation due date was 11/31/24, and it was not completed and overdue. During a review of clinical record indicated that Resident R2 was admitted [DATE]. During a review of clinical record clinical assessment summary indicated Resident R2 admission Activities Evaluation due date was 12/2/24, and it was not completed and overdue. During an interview on 12/17/24, at 1:00 p.m., Nursing Home Administrator confirmed the that admission Activities Evaluation's were not completed as required. 28 Pa. Code: 211.10(d) Resident care policies. 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: 396048 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 396048 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2024 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)