Health inspection·January 23, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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, controlled medication shift reconciliation records and staff interviews, it was determined that the facility failed to implement procedures to promote accurate accounting of controlled medications on five of five medication carts reviewed (2 North, 2 South, 3 East, Memory Impaired Unit (MIU), and 3 South). Findings include: Review of facility policy Inventory Control of Controlled Substances dated 8/28/24, indicated facility should ensure that the incoming and outgoing nurses count all Schedule II controlled substances and other medications with a risk of abuse or diversion at the change of each shift or at least once daily and document the results on a Controlled Substance Count Verification/Shift Count Sheet. During a review of the Controlled Medication Shift Reconciliation log for the 3 East Medication Cart on 1/22/25, at 1:11 p.m. revealed the oncoming nurse and/or outgoing nurse failed to sign the sheet during shift change to verify counts of controlled drugs on the following dates: - 1/1/25, oncoming nurse for 11 p.m. shift - 1/2/25, outgoing nurse for 7 a.m. shift - 1/3/25, outgoing nurse for 7 a.m. shift - 1/17/25, oncoming nurse for 11 p.m. shift - 1/19/25, oncoming nurse for 11 p.m. shift - 1/20/25, outgoing nurse for 7 a.m. shift During an interview on 1/22/25, at 1:13 p.m. Licensed Practical Nurse (LPN) Employee E2 confirmed the above observations and stated, There should be signatures there. During a review of the Controlled Medication Shift Reconciliation log for the MIU Medication Cart on 1/22/25, at 1:15 p.m. revealed the oncoming nurse and/or outgoing nurse failed to sign the sheet during shift change to verify counts of controlled drugs on the following dates: - 1/2/25, oncoming nurse for 11 p.m. shift - 1/3/25, outgoing nurse for 7 a.m. shift - 1/11/25, outgoing nurse for 11 p.m. shift - 1/13/25, oncoming nurse for 7 a.m. shift, and outgoing nurse for 3 p.m. shift - 1/16/25, outgoing nurse for 3 p.m. shift - 1/17/25, outgoing nurse for 11 p.m. shift (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396048 If continuation sheet Page 2 of 4 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 01/23/2025 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)

F 0755 During an interview on 1/22/25, at 1:19 p.m. LPN Employee E3 confirmed the above observations. Level of Harm - Minimal harm or potential for actual harm During a review of the Controlled Medication Shift Reconciliation log for the 3 South Medication Cart on 1/22/25, at 1:21 p.m. revealed the oncoming nurse and/or outgoing nurse failed to sign the sheet during shift change to verify counts of controlled drugs on the following dates: Residents Affected - Many - 1/11/25, outgoing nurse for 11 p.m. shift - 1/12/25, outgoing nurse for 7 a.m. shift and outgoing nurse for 11 p.m. shift - 1/18/25, outgoing nurse for 11 p.m. shift During an interview on 1/22/25, at 1:22 p.m. LPN Employee E4 confirmed the above observations. During a review of the Controlled Medication Shift Reconciliation log for the 2 South Medication Cart on 1/22/25, at 1:24 p.m. revealed the oncoming nurse and/or outgoing nurse failed to sign the sheet during shift change to verify counts of controlled drugs on the following dates: - 1/4/25, oncoming nurse for 11 p.m. shift - 1/5/25, outgoing nurse for 7 a.m. shift - 1/6/25, oncoming nurse for 11 p.m. shift - 1/7/25, oncoming and outgoing nurse for 7 a.m. shift, oncoming and outgoing nurse for 3 p.m. shift, and outgoing nurse for 11 p.m. shift - 1/14/25, oncoming nurse for 3 p.m. shift, and outgoing and coming nurse for 11 p.m. shift - 1/17/25, outgoing nurse for 7 a.m. shift - 1/18/25, outgoing nurse for 7 a.m. shift - 1/21/24, oncoming nurse for 3 p.m. shift, and outgoing nurse for 11 p.m. shift During an interview on 1/22/25, at 1:24 p.m. LPN Employee E5 confirmed the above observations. During a review of the Controlled Medication Shift Reconciliation log for the 2 North Medication Cart on 1/22/25, at 1:26 p.m. revealed the oncoming nurse and/or outgoing nurse failed to sign the sheet during shift change to verify counts of controlled drugs on the following dates: - 1/2/25, outgoing nurse for 11 p.m. shift - 1/7/25, oncoming nurse for 3 p.m. shift, and outgoing nurse for 11 p.m. shift - 1/11/25, oncoming nurse for 3 p.m. shift, and outgoing nurse for 11 p.m. shift - 1/12/25, oncoming nurse for 7 a.m. shift, outgoing and oncoming nurse for 3 p.m. shift, and outgoing nurse for 11 p.m. shift (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396048 If continuation sheet Page 3 of 4 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 01/23/2025 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)

F 0755 - 1/16/25, outgoing and oncoming nurse for 3 p.m. shift, and outgoing and oncoming nurse for 11 p.m. shift Level of Harm - Minimal harm or potential for actual harm - 1/17/25, outgoing nurse for 7 a.m. shift, outgoing and oncoming nurse for 3 p.m. shift, and outgoing and oncoming nurse for 11 p.m. shift Residents Affected - Many - 1/18/25, outgoing nurse for 7 a.m. shift, and oncoming nurse for 11 p.m. shift - 1/19/25, outgoing and oncoming nurse for 7 a.m. shift, and outgoing nurse for 3 p.m. shift During an interview on 1/22/25, at 1:28 p.m. LPN Employee E5 confirmed the above observations. During an interview on 1/22/25, at 1:4 p.m. the Nursing Home Administrator confirmed that the facility failed to implement procedures to promote accurate accounting of controlled medications on five of five medication carts as required. 28 Pa. Code 211.12 (d)(3)(5) Nursing services 28 Pa. Code 211.19(a)(1)(k) Pharmacy services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396048 If continuation sheet Page 4 of 4