Harmar Village: Vaccine Tracking Failures - PA

Federal inspectors discovered the tracking failures during an April inspection, finding that staff couldn't provide medical record documentation showing whether residents with diabetes, stroke, and Parkinson's disease received proper vaccine evaluations when they came due.

Resident R12, who has diabetes, stroke, and seizure disorder, was supposed to have a pneumococcal vaccine assessment on March 26, 2025. Nearly a year later, on March 31, 2026, Infection Preventionist Employee E10 told inspectors the facility couldn't provide documentation that the assessment ever happened.

The consequences of missing pneumococcal vaccines can be severe for nursing home residents. Pneumonia kills more nursing home residents than any other infection, with death rates particularly high among people with diabetes and stroke survivors.

Resident R44 faced a similar documentation gap. This resident, who has stroke, hemiplegia, and Parkinson's disease, was due for pneumococcal vaccine assessment on April 28, 2025. Again, the facility had no medical record documentation to show the assessment occurred.

Both residents had been admitted months before their vaccine assessments came due, giving staff ample time to establish tracking systems. Resident R12 was admitted with a history that included diabetes and seizure disorder alongside stroke damage. Resident R44 arrived with paralysis on one side of the body from stroke, complicated by Parkinson's disease tremors.

The facility's own infection prevention policy, dated August 15, 2025, specifically assigns the Infection Preventionist responsibility for overseeing vaccination strategies. The policy requires the IP to "ensure oversight of the infection prevention committee strategies and approaches to prevent and/or address, at a minimum vaccinations."

Employee E10, the Infection Preventionist, acknowledged the documentation failures during the inspector interview. The admission came after inspectors reviewed immunization records that showed when vaccines were due but found no corresponding documentation in the electronic health record system.

Regional Risk Employee E9 confirmed the facility's failure during a separate interview at 3:00 p.m. on March 31. The regional employee verified that Harmar Village had failed to ensure pneumococcal vaccinations were properly tracked in electronic health records for both residents.

The tracking failure represents more than paperwork problems. Pneumococcal vaccines protect against pneumonia and other serious infections caused by pneumococcus bacteria. For residents with underlying conditions like diabetes, stroke, and Parkinson's disease, these infections can be life-threatening.

Diabetes compromises immune system function, making infections harder to fight off. Stroke survivors often have weakened cough reflexes and difficulty swallowing, increasing pneumonia risk. Parkinson's disease can affect breathing muscles and swallowing coordination, creating additional vulnerability to respiratory infections.

The inspection found the facility had systems in place to track when vaccines came due. Immunization records clearly indicated the March and April 2025 assessment dates for both residents. But the electronic health record system, which should document whether assessments actually occurred, contained no such evidence.

Without proper documentation, the facility cannot prove it evaluated whether residents needed vaccines, whether vaccines were administered, or whether residents declined them. The missing records leave a gap in the medical history that could affect future care decisions.

The documentation failures affected residents who had been in the facility long enough for staff to establish complete medical records. Neither resident was a recent admission struggling with initial paperwork. Both had been assessed through the facility's Minimum Data Set process, which captures detailed information about diagnoses and care needs.

The inspection revealed systemic problems with vaccine tracking rather than isolated oversights. Two separate residents, with different admission dates and different due dates for assessments, both experienced the same documentation failure nearly a year apart.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Harmar Village Health & Rehab Center from 2026-04-03 including all violations, facility responses, and corrective action plans.

Additional Resources

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