Harmar Village: Medical Records Errors Affect 14 Residents - PA
When inspectors reviewed the facility's paper report sheets in November 2025, they found a document that had drifted badly from reality. Resident R46 was still listed on the sheet. R46 had already died. Resident R47 was also still listed, with a DNR/DNI code status printed next to the name. R47 had also died. Two other residents, R38 and R42, remained on the sheet after being discharged from the facility.
The errors that carried the most immediate consequence involved code status, the designation that tells staff whether to attempt to save a resident's life if their heart stops. Resident R17 was documented on the report sheet as a full code, meaning staff would be directed to start CPR and use every available measure to resuscitate. R17's physician order said DNR/DNI. The electronic chart said the same thing. The sheet said the opposite.
The same mismatch appeared for Resident R33. The report sheet said full code. The physician order said DNR/DNI. The electronic chart said DNR. And for Resident R43: the pre-printed information on the sheet said full code. The physician order said DNR/DNI.
Resident R21's name had been written into the wrong bed location entirely, placed at R40's spot on the sheet. The printed information next to R21's name indicated full code. R21's physician order, dated the same period, indicated DNR. R40's actual bed location was left blank.
Three other residents, R14, R39, and R41, had their names written onto the sheet with no designation at all for how their medications were to be administered. That gap mattered for at least one of them. R14's physician order required crushed medications. Nothing on the sheet reflected that.
The Director of Nursing, interviewed by inspectors at approximately 12:00 p.m. on the day of the inspection, confirmed there had been a breakdown in communication between the speech therapy department and the nursing department about which residents had physician orders for crushed medications. Thirty minutes later, the Nursing Home Administrator and the Director of Nursing sat together with inspectors and confirmed that the report sheets were inaccurate. They confirmed the facility had failed to maintain complete and accurate medical records for 14 of its 104 residents.
Resident R32 had no information at all in the bed location section of the sheet. R32 had been admitted, then readmitted following a hospitalization. Neither stay had produced an accurate entry. Resident R37's name was simply missing from the sheet. Resident R40's correct bed location was blank.
What the sheet captured, in other words, was a version of the unit that no longer existed: residents who had died still occupying beds, residents who had left still assigned to rooms, and residents very much alive and present whose most basic care instructions were either wrong or absent.
The inspection was a complaint survey, meaning someone had contacted regulators before inspectors arrived. CMS rated the deficiency at the level of minimal harm or potential for actual harm, affecting some residents.
That rating reflects what was documented, not necessarily what was risked. A nurse responding to a cardiac event in the middle of a night shift does not pause to cross-reference the electronic chart against the paper sheet. The sheet is what is in hand. For three residents at Harmar Village, that sheet would have directed staff to attempt resuscitation on people who had explicitly refused it.
The administrator and director of nursing did not dispute any of it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Harmar Village Health & Rehab Center from 2025-11-15 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 22, 2026 · Our methodology
HARMAR VILLAGE HEALTH & REHAB CENTER in CHESWICK, PA was cited for violations during a health inspection on November 15, 2025.
When inspectors reviewed the facility's paper report sheets in November 2025, they found a document that had drifted badly from reality.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.