Harmar Village Health & Rehab Center

In the surveyor’s words

From the most serious findings on record at Harmar Village Health & Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Nov 15, 2025

  Based on review of facility policy, clinical record review, and interviews with staff, it was determined that the facility failed to accurately document the need to crush medications for 29 of 33 residents (Resident R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, and R36) and failed to ensure that residents are free of significant medication errors which resulted in an immediate jeopardy situation for one of five residents (Resident R1).Findings include: Facility policy, General Dose Preparation and Medication Administration revealed staff will Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct… […]

• Immediate jeopardy, isolatedF689May 9, 2025

  Based on review of facility policy and documents, clinical records, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision and failed to identify a resident who was an elopement risk which resulted in an elopement for one of five residents (Resident R1). This failure created an immediate jeopardy situation. Findings include: Review of the facility Elopement/Unauthorized Absence Policy policy dated 8/2/24, last reviewed 3/20/25, indicated the facility will identify residents with potential and/or actual risk factors for elopement and protect the resident through development and implementation of safety interventions. […]

• Immediate jeopardy, isolatedF689Aug 1, 2024

  Based on review of facility policy, clinical records, facility documents, resident interview, and staff interviews, it was determined that the facility failed to identify a resident's risk for elopement and failed to make certain each resident received adequate supervision that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one resident (Resident R1). This failure created an immediate jeopardy situation for one of 96 residents (Resident R1), who was not properly identified as an elopement risk, and the facility failed to document the appropriate assistance level for one of three residents (Resident R2), and failed to provide appropriate assistance to prevent an avoidable fall for one of three residents reviewed… […]

• Actual harm, isolatedF600Nov 15, 2025

  Based on review of facility policy, clinical records, and staff interviews, it was determined the facility failed to implement policies and procedures to protect residents from neglect that resulted in the actual harm of choking and subsequent death for one of five residents (Resident R1).Findings include: Review of facility Pennsylvania Resident Abuse Policy dated 10/23/25, revealed neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of Resident R1's clinical record revealed Resident R1 was admitted to the facility on [DATE]. […]

• Actual harm, isolatedF908Nov 15, 2025

  Based on observations and staff interviews it was determined the facility failed to ensure equipment was in safe operating condition for two of two crash carts (carts maintained with equipment used in emergencies) which caused the actual harm of a delay in emergency care for one of five residents (Resident R1).Findings include: Review of the facility Emergency Equipment Check Policy dated 10/23/25, revealed, Emergency equipment/cart(s) will be checked daily and items which are outdated or opened will be replaced. The cart will be restocked promptly after any use. Check contents against community-specific emergency cart contents checklist. Replace missing items and items that have been opened. Initial/sign community specific emergency cart check sheet. […]