Pennsylvania Department of Health
HARMAR VILLAGE HEALTH & REHAB CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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HARMAR VILLAGE HEALTH & REHAB CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: - Component: -- - Tag: 0000

Based on an Emergency Preparedness Survey completed on March 24, 2026, it was determined that Harmar Village Health and Rehab Center had deficiencies that have the potential for minimal harm as related to the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(a), 416.54(a), 418.113(a), 441.184(a), 482.15(a), 483.475(a), 483.73(a), 484.102(a), 485.542(a), 485.625(a), 485.68(a), 485.727(a), 485.920(a), 486.360(a), 491.12(a), 494.62(a) STANDARD Develop EP Plan, Review and Update Annually:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

§403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a).

The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements:

(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following:

* [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach.

* [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually.

* [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years.

.

Observations:
Name: - Component: -- - Tag: 0004
Based on a review of the facility's Emergency Preparedness (EP) Plan, it was determined the facility failed to review and update their emergency plan at least annually.

Findings include:

1. Interview and documentation review on March 24, 2026, at 8:45 a.m., revealed the Emergency Preparedness Plan was not updated in over 12 months.

Interview with the Facility Administrator and Maintenance Director on March 24, 2026, at 8:45 a.m., confirmed the EP plan was not reviewed and updated at least annually.

Plan of Correction - To be completed: 04/23/2026

Facility emergency preparedness plan manual was updated as of 3/24/26.

Maintenance director educated regarding the importance of keeping EPP current and annual review.

Facility will audit compliance with regulatory requirements weekly times 30 days.

403.748(a)(1)-(2), 416.54(a)(1)-(2), 418.113(a)(1)-(2), 441.184(a)(1)-(2), 482.15(a)(1)-(2), 483.475(a)(1)-(2), 483.73(a)(1)-(2), 484.102(a)(1)-(2), 485.542(a)(1)-(2), 485.625(a)(1)-(2), 485.68(a)(1)-(2), 485.727(a)(1)-(2), 485.920(a)(1)-(2), 486.360(a)(1)-(2), 491.12(a)(1)-(2), 494.62(a)(1)-(2) STANDARD Plan Based on All Hazards Risk Assessment:

§403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2)

[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:]

(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.*

(2) Include strategies for addressing emergency events identified by the risk assessment.

* [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.
(2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care.

*[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents.
(2) Include strategies for addressing emergency events identified by the risk assessment.

*[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:

(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients.
(2) Include strategies for addressing emergency events identified by the risk assessment.

Observations:
Name: - Component: -- - Tag: 0006

Based on document review and interview it was determined that the facility failed to provide a written Emergency Preparedness Plan that includes a facility-based and community-based risk assessment.

Findings include:

1. Interview and documentation review on March 24, 2026, at 8:50 a.m., revealed the facility lacked an Emergency Preparedness Plan that includes a facility-based and community-based risk assessment, utilizing an all-hazards approach.

Interview with the Facility Administrator on March 24, 2026, at 8:50 a.m., confirmed the facility Emergency Preparedness Plan lacked a facility-based and community-based risk assessment.

Plan of Correction - To be completed: 04/23/2026

on 3/24/2026 EPP plan manual was updated to include facility-based and community-based risk assessment.

Maintenance director educated regarding the importance of the above mentioned risk assessment in the EPP manual.

Maintenance director/designee will audit the EPP for the presence of facility-based and community-based risk assessment weekly x 4 weeks.

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID#077802
Component 01
Main building

Based on a Medicare/Medicaid Recertification Survey completed on March 24, 2026, it was determined that Harmar Village Health and Rehab Center was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a three-story, Type II (222), fire resistive building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Multiple Occupancies:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

Multiple Occupancies - Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of the following:

o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access.
o They are separated from areas of health care occupancies by
construction having a minimum two hour fire resistance rating in
accordance with Chapter 8.
o The entire building is protected throughout by an approved, supervised
automatic sprinkler system in accordance with Section 9.7.

Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.
19.1.3.3, 42 CFR 482.41, 42 CFR 485.623

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0131

Based on observation and interview, it was determined the facility failed to maintain a two-hour fire resistance rating to separate the health care occupancy from other occupancies between the nursing home and the assisted living building, affecting one of seven smoke compartments.

Findings include:

1. Observation on March 24, 2026, at 9:30 a.m., revealed the door between Skilled Nursing and Assisted Living was chained to a chain link fence in the basement and could not close.

Interview with the Facility Administrator and Maintenance Director on March 24, 2026, at 12:30 p.m., confirmed the occupancy separation door deficiency.

Plan of Correction - To be completed: 04/23/2026

Facility unchained door between skilled nursing and assisted living and door was closed immediately. Chain that anchored door was removed.

Education provided to maintenance director regarding regulatory requirements of fire doors.

Fire doors being audited weekly x30 days.

NFPA 101 STANDARD Cooking Facilities:

Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324

Based on observation and interview, it was determined the facility failed to maintain cooking facilities in one instance, affecting one of seven smoke compartments.

Findings include:

1. Observation and document review on March 24, 2026, at 9:00 a.m., revealed the kitchen staff failed to record monthly visual checks of the kitchen fire suppression system.

Interview with the Facility Administrator and Maintenance Director on March 24, 2026, at 12:30 p.m., confirmed there was no record of the monthly checks at the time of the survey.

Plan of Correction - To be completed: 04/23/2026

On 3/24/2026 service called to Summit for service. Summit came on 3/25/2026 and completed monthly fire suppression check and applied new tag.

Maintenance director/designee will audit all fire suppression systems weekly x30 days.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345

Based on documentation review and interview, it was determined the facility failed to maintain the fire alarm system in one instance, affecting the entire facility

Findings Include:

1. Observation on March 24, 2026, at 9:45 a.m., revealed the facility failed to install a heat detector or a smoke detector at the location of the main fire alarm control panel.

Interview with the Facility Administrator and Maintenance Director on March 24, 2026, at 12:30 p.m., confirmed the fire alarm system deficiency.

Plan of Correction - To be completed: 04/23/2026

On 3/24/26, Maintenance Director called Summit for heat/smoke detector installation in Electrical room by therapy gym. Waiting for summit to install both smoke and heat detector in the Electrical Room. Education provided to Maintenance Director regarding regulatory requirements of smoke and heat detectors in Electrical room. Maintenance Director/Designee will conduct weekly audit for smoke and heat detectors in all electrical rooms x4 weeks.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in five instances, affecting four of seven smoke compartments.

Findings include:

1. Observation on March 24, 2026, revealed the following automatic sprinkler system deficiencies:

a) 9:25 a.m., there were multiple dirty/dusty sprinkler heads on 3 South outside of Rooms 312 and 313.
b) 9:40 a.m., there were multiple dirty/dusty sprinkler heads on 3 North, outside of Rooms 331 and 332;
c) 10:10 a.m., there were multiple dirty/dusty sprinkler heads on 2 North, outside of Rooms 218 and 220;
d) 10:45 a.m., there were multiple dirty/dusty sprinkler heads on the first floor outside of the Receiving Room;
e) 11:15 a.m., there was a large gap in the ceiling tile surrounding a pipe above the Pressure Washer Room in the Kitchen.

Interview with the Facility Administrator and Maintenance Director on March 24, 2026, at 12:30 p.m., confirmed the automatic sprinkler system deficiencies.

Plan of Correction - To be completed: 04/23/2026

on 3/24/2026 Maintenance director cleaned sprinkler heads 312,313,331,332,218,220 as well as sprinkler heads outside receiving room with compressed air.

On 3/24/2026 Maintenance director used fire caulking to fix large gap in the ceiling tile surrounding pipe above the pressure washer room in kitchen.

Maintenance director was educated regarding regulatory requirements regarding sealed penetration of pipes in the building and functional/cleanliness of sprinkler heads.

Maintenance director/designee will audit all sprinkler heads and pipe penetration in the building weekly/ 4 weeks.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain smoke barrier doors in one instance, affecting two of seven smoke compartments.

Findings include:

1. Observation on March 24, 2026, at 8:35 a.m., revealed the smoke barrier doors on Floor 3 leading into the MIU, had a large gap beween the doors when closed and were not smoke tight.

Interview with the Facility Administrator and Maintenance Director on March 24, 2026, at 12:30 p.m., confirmed above listed smoke barrier door deficiency.

Plan of Correction - To be completed: 04/23/2026

On 3/24/26 maintenance director installed fire strip to the MIU fire door and ensured tight seal when doors are closed.

Maintenance director was educated regarding regulatory requirements on all fire doors in the building.

Maintenance director/designee will audit all fire doors in building to ensure tight seal when doors are closed weekly x 30 days.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0920

Based on observation and interview, it was determined the facility failed to maintain the electrical wiring systems and equipment in one instance, in one of over 50 rooms inspected.

Findings include:

1. Observation on March 24, 2026, at 11:25 a.m., revealed there was a refrigerator and microwave plugged into a power-strip extension cord in the RNAC's office.

Interview with the Facility Administrator and Maintenance Director on March 24, 2026, at 12:30 p.m., confirmed the listed electrical wiring system deficiency.

Plan of Correction - To be completed: 04/23/2026

on 3/24/2026 Maintenance director removed power strip in RNAC office.

Education provided to RNACs and Maintenance director regarding regulatory compliance with use of power strip and fire safety.

Maintenance director/ designee will audit the use of power strip in all offices in building weekly 30days.

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