Deficiencies per Year
28
21
14
7
0
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 45
Capacity: 110
Deficiencies: 5
Sep 15, 2025
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial review on 09/15/2025 and 09/16/2025 to assess compliance with submitted plans of correction and regulatory requirements.
Findings
The facility was found to have multiple deficiencies related to medication management, including improper handling and documentation of medications, failure to follow prescriber's orders, and incomplete support plans for residents. The facility submitted plans of correction which were reviewed and accepted, with ongoing audits and education planned to ensure compliance.
Complaint Details
The inspection was complaint-driven, with the reason for the visit explicitly stated as 'Complaint' and the inspection being unannounced. The submitted plan of correction was reviewed and determined to be fully implemented.
Deficiencies (5)
| Description |
|---|
| Medication was not kept in original labeled containers; bottles were combined and altered the Controlled Medication Accountability Record. |
| Medication administration times were not properly recorded or documented as required. |
| Failure to follow prescriber's orders regarding medication administration. |
| The weekly activity calendar was not posted in a conspicuous and public place; only the August 2025 calendar was posted during the inspection. |
| Support plans did not document the presence and use of wheelchair lap belts and bilateral bedside mobility devices for residents. |
Report Facts
License Capacity: 110
Residents Served: 45
Total Daily Staff: 51
Waking Staff: 38
Current Hospice Residents: 2
Residents Age 60 or Older: 45
Residents with Mobility Need: 6
Inspection Report
Complaint Investigation
Census: 41
Capacity: 110
Deficiencies: 0
May 5, 2025
Visit Reason
The inspection was conducted as a complaint investigation with a partial, unannounced visit on 05/05/2025.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related and the findings indicate no deficiencies or citations, implying the complaint was not substantiated.
Report Facts
License Capacity: 110
Residents Served: 41
Resident Demographics: 41
Resident Demographics: 5
Inspection Report
Follow-Up
Census: 64
Capacity: 133
Deficiencies: 1
Aug 19, 2024
Visit Reason
The inspection was a partial announced visit conducted on 08/19/2024 and 09/04/2024 as a follow-up to a complaint, incident, and fine, with a plan of correction submission due on 09/27/2024.
Findings
The submitted plan of correction related to water damage on ceilings caused by sprinkler system repairs was fully implemented and verified by photo proof on 09/04/2024. The facility demonstrated compliance with corrective actions including timely repairs and monitoring procedures.
Complaint Details
The inspection was complaint-related, involving a complaint, incident, and fine. The plan of correction was submitted and accepted, with follow-up inspections confirming compliance.
Deficiencies (1)
| Description |
|---|
| There was a large circular area of water damage on the ceiling above the television in a bedroom caused by sprinkler system repairs, and an area where the ceiling had fallen down in an unoccupied bedroom. |
Report Facts
License Capacity: 133
Residents Served: 64
Special Care Unit Capacity: 23
Special Care Unit Residents Served: 21
Hospice Residents: 6
Staffing Hours: 87
Waking Staff: 65
Inspection Report
Complaint Investigation
Census: 68
Capacity: 133
Deficiencies: 2
May 28, 2024
Visit Reason
The inspection was conducted as a complaint investigation to review compliance issues at THE VILLAGES OF HARMAR facility.
Findings
The inspection found deficiencies related to the failure to provide a final itemized written account of resident funds within 30 days of discharge and incomplete support plans that did not specify plans to meet each resident diagnosis. Plans of correction were submitted and accepted.
Complaint Details
The visit was complaint-related. The complaint involved a resident not receiving a final itemized written account of funds within 30 days of discharge. The complaint was investigated and resolved with corrective actions.
Deficiencies (2)
| Description |
|---|
| Failure to provide a final itemized written account of resident funds within 30 days of discharge. |
| Support plan did not include specific plans to meet each diagnosis for resident #2. |
Report Facts
License Capacity: 133
Residents Served: 68
Special Care Unit Capacity: 23
Special Care Unit Residents Served: 21
Current Hospice Residents: 7
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 23
Residents 60 Years or Older: 68
Inspection Report
Complaint Investigation
Census: 72
Capacity: 133
Deficiencies: 22
Feb 27, 2024
Visit Reason
The inspection was conducted due to a renewal, complaint, and provisional license review of The Villages of Harmar facility.
Findings
Multiple violations were found including issues with resident abuse, medication administration errors, confidentiality breaches, fire safety deficiencies, and incomplete resident assessments and support plans. The facility was issued a second provisional license and required to submit plans of correction.
Complaint Details
The complaint involved an incident where a staff person sprayed a resident in the face with spray dust remover and failed to immediately suspend the staff involved or report the incident to the Department. The incident was substantiated and the staff person was terminated.
Deficiencies (22)
| Description |
|---|
| Resident records were unlocked, unattended, and accessible, violating confidentiality requirements. |
| Battery-operated carbon monoxide detector lacked date of battery installation. |
| Resident medical evaluations and resident-residence contracts were not completed timely or accurately. |
| Staff dementia-specific training was incomplete for some employees. |
| Unsafe bed enablers posed entrapment hazards. |
| Windows lacked screens and were not secure. |
| Resident bedside lamp was inoperable. |
| Food items were stored unsealed in freezers. |
| Emergency procedures were not reviewed and submitted annually to local emergency management agency. |
| Fire safety inspection and fire drills were outdated or incomplete. |
| Fire drill records lacked required details such as evacuation times, exit routes, and resident counts. |
| Residents were not always evacuated to designated meeting places during fire drills. |
| Resident medical evaluations lacked required tuberculin skin test documentation. |
| Medication labels did not always match physician orders. |
| Medications were not always available or stored properly. |
| Medication administration was not always documented at the time of administration. |
| Resident assessments and support plans were incomplete or inaccurate. |
| Resident abuse incident was not immediately reported or managed with appropriate supervision. |
| Staff did not consistently use communication devices to contact other staff in emergencies. |
| Staff administering medications lacked current certification or training. |
| Staff administered insulin without completing required diabetes education. |
| Resident records contained correction fluid on important documents. |
Report Facts
License Capacity: 133
Residents Served: 72
Special Care Unit Capacity: 23
Special Care Unit Residents Served: 18
Current Hospice Residents: 6
Staffing Hours: 95
Waking Staff: 71
Fines Calculated: 213
Fines Calculated: 355
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Involved in resident abuse incident where resident was sprayed with dust remover. | |
| Staff person B | Administered medications without completing annual medication administration practicum. | |
| Staff person C | Administered medications and insulin without completing required training. | |
| Staff person D | Witnessed abuse incident involving staff person A and resident #1. | |
| Administrator | Conducted education and implemented plans of correction related to multiple violations. |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 133
Deficiencies: 26
Feb 27, 2024
Visit Reason
The inspection was conducted due to a combination of renewal, complaint, and provisional licensing concerns, including multiple licensing inspections and complaint investigations.
Findings
Multiple violations were found including confidentiality breaches, medication errors, incomplete medical evaluations, abuse incidents, fire safety deficiencies, and documentation issues. The facility was issued a second provisional license with required plans of correction and follow-up inspections.
Complaint Details
The complaint involved allegations of abuse where a staff person sprayed a resident in the face and eyes with spray dust remover and failed to immediately suspend the staff involved. The incident was substantiated and staff was terminated. The incident was not initially reported to the Department within required timeframes but was later reported. Additional abuse and neglect concerns were documented involving resident-to-resident aggression.
Deficiencies (26)
| Description |
|---|
| Medical information and records for numerous residents were unlocked, unattended and accessible at multiple nursing stations. |
| Battery-operated carbon monoxide detector lacked date of battery installation. |
| Resident medical evaluation was not completed within required timeframes. |
| Resident-residence contract was not signed timely or by all required parties. |
| Direct care staff person had incomplete dementia-specific training. |
| Bilateral enablers on resident's bed were not securely attached and posed entrapment hazard. |
| Window near living unit lacked screen and was unsafe to open. |
| Resident's bedside lamp was inoperable. |
| Open and unsealed food items were present in freezers. |
| Emergency procedures had not been reviewed and submitted to local emergency management agency annually. |
| Fire safety inspection and fire drill were not conducted annually by a fire safety expert. |
| Fire drill records lacked required details including evacuation time, exit routes, and number of residents evacuated. |
| No written documentation from a fire safety expert indicating evacuation time within required limits. |
| Alternate exit routes were not documented as used during fire drills. |
| Residents did not evacuate to a designated meeting place during fire drills. |
| Resident medical evaluations lacked required documentation of tuberculin skin tests. |
| Resident medications were not labeled correctly per pharmacy label requirements. |
| Medication was not present in the residence for administration as prescribed. |
| Medications were administered but not documented at the time of administration. |
| Resident was neglected and verbally abused by staff spraying dust remover in resident's face and eyes. |
| Staff did not regularly use communication system to contact other staff for assistance in emergencies. |
| Staff persons administering medications had not completed required annual practicums or training. |
| Staff administered insulin without completing required diabetes patient education program. |
| Resident records contained correction fluid on important documents. |
| Resident assessments and support plans were incomplete or inaccurate regarding care needs and medical history. |
| Resident support plan was not signed by required individuals. |
Report Facts
License Capacity: 133
Residents Served: 72
Special Care Unit Capacity: 23
Residents Served in Special Care Unit: 18
Staffing Hours: 95
Waking Staff: 71
Number of Violations with Fines: 8
Fine Amount Per Day: 355
Residents Served: 74
Residents Served: 71
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in abuse incident involving spraying resident in face and eyes; terminated following investigation. | |
| Staff person D | Witnessed abuse incident and reported it; unable to suspend staff person A. |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 133
Deficiencies: 28
Feb 27, 2024
Visit Reason
The inspection was conducted due to a combination of renewal, complaint, and provisional reasons, including multiple licensing inspections and complaint investigations.
Findings
The inspection identified multiple violations including confidentiality breaches, medication administration errors, incomplete medical evaluations, abuse incidents, fire safety deficiencies, and documentation issues. Plans of correction were proposed or implemented for all findings.
Complaint Details
The complaint involved allegations of abuse where a staff person sprayed a resident in the face and eyes with spray dust remover and continued to work unsupervised. The incident was substantiated and staff person was terminated. The incident was not reported timely to the Department but was later reported. Additional abuse and aggressive behaviors by resident #1 towards other residents were documented.
Deficiencies (28)
| Description |
|---|
| Medical information and records for numerous residents were unlocked, unattended and accessible at multiple nurses stations. |
| Battery-operated carbon monoxide detector did not include the date of battery installation. |
| Resident medical evaluation was not completed within required timeframes. |
| Resident-residence contract was not signed timely or by all required parties. |
| Direct care staff person did not complete required dementia-specific training. |
| Bilateral enablers at resident's bed were not securely attached and posed an entrapment hazard. |
| Window in hallway near living unit lacked a screen and was unable to stay open independently. |
| Resident's bedside lamp was inoperable. |
| Numerous open and unsealed food items were present in freezers. |
| Written emergency procedures had not been reviewed and submitted annually to local emergency management agency. |
| Fire safety inspection and fire drill were not conducted annually by a fire safety expert. |
| Fire drill records lacked required details including evacuation time, exit routes, number of residents evacuated. |
| Residence lacked written documentation from a fire safety expert indicating evacuation time within required limits. |
| Alternate exit routes were not documented as used during fire drills. |
| Residents did not evacuate to a designated meeting place during fire drills. |
| Resident medical evaluations lacked documentation of required tuberculin skin tests. |
| Resident medications were not labeled correctly according to pharmacy labels and physician orders. |
| Medication was not present in the residence for administration as prescribed. |
| Medications were administered but not documented at the time of administration. |
| Resident assessment and support plans were incomplete or unsigned. |
| Correction fluid was present on resident records and medical forms. |
| Staff person administered medications without completing required annual practicums or training. |
| Staff person administered insulin injections without completing required diabetes education. |
| Resident abuse incident where staff sprayed resident in face with spray dust remover; staff continued to work unsupervised until end of shift. |
| Staff persons witnessed resident-to-resident physical aggression and multiple aggressive behaviors documented. |
| Staff persons did not regularly use the residence's communication system to contact other staff for assistance in emergencies. |
| Discontinued medication was still present and administered to resident in error. |
| Resident assessment did not include all required care needs and support plans lacked specific plans to meet diagnoses. |
Report Facts
License Capacity: 133
Residents Served: 72
Special Care Unit Capacity: 23
Special Care Unit Residents Served: 18
Hospice Residents: 6
Resident Support Staff: 0
Total Daily Staff: 95
Waking Staff: 71
Inspection Dates: 7
Fines: 213
Fines: 355
Residents Served: 74
Residents Served: 71
Special Care Unit Residents Served: 20
Special Care Unit Residents Served: 21
Hospice Residents: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in abuse incident involving spraying resident in face and eyes | |
| Staff person B | Named for medication administration without completing annual practicums | |
| Staff person C | Named for medication administration and insulin injections without required training | |
| Staff person D | Witnessed abuse incident and reported it late |
Inspection Report
Follow-Up
Census: 65
Capacity: 133
Deficiencies: 9
Jan 23, 2024
Visit Reason
The inspection was a follow-up visit triggered by a complaint and incident to verify the implementation of a previously submitted plan of correction.
Findings
The facility had multiple deficiencies related to environmental hazards, fire safety evacuation procedures, incomplete resident medical evaluations, and medication management issues including expired medications, improper storage, labeling errors, and failure to follow prescriber orders. The submitted plan of correction was determined to be fully implemented as of the follow-up review.
Complaint Details
The inspection was complaint-related, triggered by a complaint and incident. The complaint was substantiated as deficiencies were found and addressed through a plan of correction.
Deficiencies (9)
| Description |
|---|
| Large hole in the ceiling in the main living room area due to roof leak. |
| Residents were not fully evacuated to designated meeting place during fire alarm; only SCU residents evacuated. |
| Resident annual medical evaluations were incomplete or missing required information. |
| Expired medications found in medication cart and lack of physician order for some medications. |
| Medications stored improperly, including refrigerated medication that should be stored at room temperature. |
| Medication containers had inconsistent labeling with conflicting dosage instructions. |
| Medication administration records (MAR) lacked diagnosis or purpose for multiple medications. |
| Medication administration times were not properly recorded or medications were unavailable when documented as given. |
| Failure to follow prescriber’s orders with missed or extra medication doses for multiple residents. |
Report Facts
License Capacity: 133
Residents Served: 65
Memory Impaired Unit Capacity: 23
Memory Impaired Unit Residents Served: 14
Hospice Residents: 5
Staffing Hours: 86
Waking Staff: 65
Inspection Report
Complaint Investigation
Census: 81
Capacity: 133
Deficiencies: 0
Oct 17, 2023
Visit Reason
The inspection was conducted as a complaint investigation at THE VILLAGES OF HARMAR facility on 10/17/2023.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Report Facts
License Capacity: 133
Residents Served: 81
Memory Impaired Unit Capacity: 23
Memory Impaired Unit Residents Served: 21
Current Hospice Residents: 6
Residents Diagnosed with Mental Illness: 4
Residents with Mobility Need: 21
Residents Aged 60 or Older: 81
Residents with Physical Disability: 2
Inspection Report
Follow-Up
Census: 85
Capacity: 133
Deficiencies: 1
Sep 13, 2023
Visit Reason
The inspection was conducted as a partial, unannounced follow-up visit triggered by a complaint and incident review to verify the implementation of a submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented as of the last review dates, with continued compliance required. The report notes completion of required resident assessments and corrective actions.
Complaint Details
The inspection was complaint-related with a reason stated as Complaint, Incident. Substantiation status is not explicitly stated.
Deficiencies (1)
| Description |
|---|
| Resident #1's most recent assessment was not completed as required annually. |
Report Facts
License Capacity: 133
Residents Served: 85
Special Care Unit Capacity: 23
Special Care Unit Residents Served: 21
Hospice Current Residents: 5
Residents Age 60 or Older: 85
Residents with Mobility Need: 30
Inspection Report
Complaint Investigation
Census: 92
Capacity: 133
Deficiencies: 28
Aug 2, 2023
Visit Reason
The inspection was conducted as a complaint investigation with a partial unannounced visit on 08/02/2023 and 08/09/2023 to assess compliance with 55 Pa. Code Chapter 2800 relating to Assisted Living Residence.
Findings
Multiple deficiencies were found including telephone access issues, lack of fire safety orientation for agency staff, menu change notification failures, medication self-administration errors, medication storage and labeling issues, incomplete resident assessments and support plans, and confidentiality breaches. Plans of correction were directed or accepted with deadlines mostly in September 2023.
Complaint Details
The inspection was complaint-driven with multiple visits on 08/02/2023 and 08/09/2023. The complaint involved issues such as telephone access, medication administration, resident rights, and facility safety. The exit conference was held on 08/09/2023.
Deficiencies (28)
| Description |
|---|
| Telephone service was inoperable from approximately 7/3/23 until 7/10/23, preventing residents from making private calls. |
| Agency staff provided unsupervised direct care without receiving orientation in general fire safety and emergency preparedness. |
| Menu changes were not posted in a conspicuous and public place in advance of meals. |
| Resident #1 self-administered medications despite being assessed as unable to do so. |
| Discontinued medication found on medication cart for resident #1. |
| Pharmacy label for resident #3’s medication did not match physician’s order. |
| Medication accountability issues including missing narcotic count sheets and unaccounted medications. |
| Medication administration records lacked administration times for certain medications. |
| Medications were administered but not documented at the time of administration. |
| Failure to follow prescriber’s orders for multiple residents. |
| Residents #6, #7, and #8 did not have initial assessments or preliminary support plans within 30 days prior to admission. |
| Resident records lacked documentation of admission agreement and signed preliminary support plans. |
| Resident records and medication storage areas were not kept confidential; multiple resident documents and medications were found unlocked and unattended. |
| Poisonous materials were not kept locked and inaccessible to residents in the memory impaired unit. |
| Trash cans in resident bathrooms were uncovered and contained inappropriate items. |
| Furniture and equipment in resident areas were broken or missing parts, creating hazards. |
| Medical evaluations were missing or incomplete for some residents. |
| Medications and syringes were unlocked, unattended, and accessible in nurse’s office and resident areas. |
| Expired and improperly stored medications were found in medication carts and refrigerators. |
| Resident medication administration training documentation was incomplete and did not include competency scores. |
| Resident right to refuse medication was not documented for resident #11. |
| Resident contracts and signed statements were missing or incomplete. |
| Resident assessments and support plans were not dated or completed within required timeframes. |
| Resident records lacked photographs and demographic information. |
| Carpet in resident living unit was in disrepair creating a hazard. |
| Residents experienced delays in laundry return and missing clothing. |
| Kitchen lacked adequate counter space for cooking appliances meeting safety standards. |
| Resident rooms contained unauthorized small appliances and fire hazards. |
Report Facts
License Capacity: 133
Residents Served: 92
Special Care Unit Capacity: 23
Special Care Unit Residents Served: 23
Staffing Hours - Total Daily Staff: 115
Staffing Hours - Waking Staff: 86
Inspection Dates: 8
Inspection Report
Complaint Investigation
Census: 92
Capacity: 133
Deficiencies: 10
Aug 2, 2023
Visit Reason
The inspection was a complaint investigation conducted due to allegations and complaints received regarding the facility's compliance with regulations.
Findings
Multiple violations were found including telephone access issues, fire safety orientation deficiencies, medication administration errors, menu posting failures, incomplete resident assessments, confidentiality breaches, and unsafe storage of medications and supplies. Several plans of correction were directed or accepted with deadlines for compliance.
Complaint Details
The inspection was complaint-driven with multiple complaint allegations investigated, including medication errors, resident rights violations, and safety concerns.
Deficiencies (10)
| Description |
|---|
| Telephone service was inoperable from approximately 7/3/23 until 7/10/23, preventing residents from making private calls. |
| Agency staff provided unsupervised direct care without receiving orientation in general fire safety and emergency preparedness. |
| Agency staff worked over 40 hours without required orientation on resident rights, emergency medical plan, abuse reporting, and core competencies. |
| Menu changes were not posted in a conspicuous and public place in advance of meals. |
| Resident self-administered medications despite assessments indicating inability to self-administer. |
| Discontinued medications were found on medication carts and medication labels did not match physician orders. |
| Medication storage procedures were inadequate, with missing narcotic count sheets and unaccounted medications. |
| Medication administration records lacked administration times and documentation was incomplete or missing. |
| Prescriber orders were not consistently followed, with missed or incorrect medication administration. |
| Initial assessments and preliminary support plans were missing for several residents admitted in 2023. |
Report Facts
License Capacity: 133
Residents Served: 92
Special Care Unit Capacity: 23
Special Care Unit Residents Served: 23
Staffing Hours - Total Daily Staff: 115
Staffing Hours - Waking Staff: 86
Inspection Dates: 8
Inspection Report
Complaint Investigation
Census: 92
Capacity: 133
Deficiencies: 12
Aug 2, 2023
Visit Reason
The inspection was conducted as a complaint investigation with multiple unannounced visits on August 2 and 9, 2023, to assess compliance with 55 Pa. Code Chapter 2800 relating to Assisted Living Residence.
Findings
Multiple violations were found including telephone access issues, lack of fire safety orientation for agency staff, menu change notification failures, medication administration errors, storage and labeling deficiencies, incomplete resident assessments and support plans, and confidentiality breaches. Plans of correction were directed or accepted with deadlines mostly in September 2023.
Complaint Details
The inspection was complaint-driven with multiple visits in August 2023. The complaint involved issues such as telephone outages, medication errors, and resident care concerns. Substantiation status is not explicitly stated.
Deficiencies (12)
| Description |
|---|
| Telephone service was inoperable from approximately 7/3/23 until 7/10/23, preventing residents from making private calls. |
| Agency staff provided unsupervised direct care without receiving orientation in general fire safety and emergency preparedness. |
| Agency staff worked over 40 hours without required orientation on resident rights, emergency medical plan, abuse reporting, and core competencies. |
| Menu changes were not posted in a conspicuous and public place in advance of meals. |
| Resident self-administered medications despite medical evaluation indicating inability to self-administer. |
| Discontinued medication found on medication cart. |
| Medication label did not match physician's order. |
| Medication storage and accountability procedures were deficient, including missing narcotic count sheets and unaccounted medications. |
| Medication administration records lacked administration times and documentation at time of administration. |
| Medications were not administered as ordered by prescriber on multiple occasions. |
| Initial assessments and preliminary support plans were missing for several residents admitted in 2023. |
| Resident records lacked required documentation such as photographs, height, weight, and personal property inventory. |
Report Facts
License Capacity: 133
Residents Served: 92
Special Care Unit Capacity: 23
Special Care Unit Residents Served: 23
Hospice Current Residents: 5
Staffing Hours - Resident Support Staff: 115
Staffing Hours - Waking Staff: 86
Deficiencies Cited: 23
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