30 Reports
Notice — Mar 18, 2026
Date: Mar 18, 2026
Visit Reason
The document serves to notify Brookdale Harrisburg that their request to waive the requirement for direct care staff to have a high school diploma, GED, or active registry status has been granted under specified conditions.
Findings
The waiver is granted based on the submission of a Bachelor's Degree from outside the United States, evaluated by a professional credential evaluator. The Department will review this waiver annually during inspections to ensure compliance with conditions.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Notice — Jan 23, 2026
Date: Jan 23, 2026
Visit Reason
The document serves to notify the facility that a waiver request to 55 Pa.Code § 2600.54(a)(2) regarding direct care staff qualifications has been granted.
Findings
The waiver allows a specified employee to serve as direct care staff despite education obtained outside the United States, subject to conditions including documentation retention and annual review during inspections.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Notice — Jan 20, 2026
Date: Jan 20, 2026
Visit Reason
This document serves to notify the facility that a waiver request to 55 Pa.Code § 2600.54(a)(2) regarding direct care staff qualifications has been granted.
Findings
The waiver allows a specific employee educated outside the United States to serve as direct care staff under specified conditions, including documentation retention and annual review during inspections.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Inspection Report — Oct 21, 2025
Follow-Up
Date: Oct 21, 2025
Visit Reason
The visit was a partial, unannounced follow-up inspection to review the submitted plan of correction for previously identified deficiencies.
Findings
The facility was found to have multiple medication-related deficiencies including unlocked medications, unlabeled OTC medications, outdated prescriptions, missing medications, and failure to follow prescriber's orders. The facility submitted plans of correction and implemented training, audits, and immediate actions to address these issues.
Citations (6)
183b Meds and Syringes Locked: Multiple instances of unlocked, unattended, and accessible medications and syringes were found in resident rooms where residents could not self-administer medications.
183d Prescription Current: Several OTC medications were found without current physician orders in resident rooms and shared bathrooms.
184a Resident's Meds Labeled: Prescription medications had pharmacy labels that did not match the prescribed dosage and instructions.
184b Labeling OTC/CAM: OTC medications belonging to residents were found unlabeled with the resident's name.
185a Implement Storage Procedures: Prescribed medications were not available in the home as required.
187d Follow Prescriber's Orders: Medications were not administered as prescribed due to unavailability in the home on multiple occasions.
Report Facts
Residents Served: 48
Secured Dementia Care Unit Residents Served: 16
Hospice Current Residents: 8
Total Daily Staff: 87
Waking Staff: 65
Inspection Report — Oct 2, 2025
Enforcement
Date: Oct 2, 2025
Visit Reason
The Department of Human Services issued a notice of intent to assess fines for regulatory violations related to Personal Care Homes at Brookdale Harrisburg due to uncorrected violations.
Findings
Two uncorrected violations under 55 Pa. Code Chapter 2600 were identified, resulting in assessed fines based on the census at the time of inspection. The fines will continue to accumulate until violations are fully corrected and verified.
Citations (2)
55 Pa. Code Section 183b violation classified as Class III with fines assessed for uncorrected issues.
55 Pa. Code Section 187d violation classified as Class II with fines assessed for uncorrected issues.
Report Facts
Fine amount: 6080
Fine amount: 2280
Fine amount: 3800
Inspection Report — Jul 8, 2025
Renewal
Date: Jul 8, 2025
Visit Reason
The inspection was a full, unannounced renewal inspection with an incident reason, conducted to assess compliance with regulations and licensing requirements.
Findings
The inspection identified multiple deficiencies including medication errors, abuse reporting failures, inadequate staff training, unsafe storage of medications and poisonous materials, incomplete resident assessments and support plans, and safety hazards related to furniture and egress routes. Plans of correction were accepted but many were not implemented as of the follow-up dates.
Citations (26)
Resident #2 medication error was not reported to the Department within 24 hours.
Resident #1 was neglected and abused, with failure to provide wound care and pressure-relieving devices, resulting in hospitalization and death.
Resident #1's initial assessment and preadmission screening were incomplete or missing.
Failure to provide physical accommodations and equipment for residents with disabilities.
Failure to follow prescriber's medication orders, including missed doses for multiple residents.
Failure to provide timely access to requested records during inspection.
Failure to immediately report suspected resident abuse to the local Area Agency on Aging.
Resident records were not kept confidential; resident information was left unsecured and accessible.
No staff certified in CPR and First Aid were present during a night shift with 41 residents.
Staff person C did not receive required annual training in fire safety, resident rights, abuse reporting, falls prevention, and new population groups.
Poisonous materials were stored unlabeled and unlocked in resident rooms and common areas.
Furniture and equipment were damaged or in disrepair, posing hazards to residents.
Food was stored unlabeled, undated, and unsealed in the protein freezer.
Lint was accumulated in the dryer lint trap, posing a fire hazard.
Exit doors and egress routes were blocked, impeding safe evacuation.
Fire drill records were incomplete, missing key information such as exit routes, number of residents evacuated, and alarm status.
Residents' annual medical evaluations were not completed timely.
Medications and syringes were not kept locked and secure in resident rooms.
Medications were not stored properly, including damaged blister packs and missing PRN medications.
OTC medications were not labeled with resident names.
Discrepancies in blood sugar readings and medication availability were found, and medications were not administered as prescribed.
Medication refusals were not documented or reported to prescribers within 24 hours.
Directions for operating key-locking devices were not posted near exits in the Secure Dementia Care Unit.
Resident admission support plans were not completed within required timeframes.
Staff working in the Secure Dementia Care Unit did not complete required annual dementia care training hours.
Resident records lacked documentation of non-objection to admission or transfer to the Secure Dementia Care Unit.
Report Facts
Residents Served: 40
Staffing Hours: 61
Waking Staff: 46
Fines Calculated: 760
Residents with Mobility Need: 21
Residents 60 Years or Older: 24
Residents Diagnosed with Mental Illness: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed the provisional license letter (page 4). |
Notice — Apr 8, 2025
Date: Apr 8, 2025
Visit Reason
This document serves to notify the facility of the granted waiver for a direct care staff member's educational qualifications under 55 Pa.Code § 2600.54(a)(2).
Findings
The waiver is granted with conditions requiring documentation of education and training to be maintained and reviewed annually during the facility's inspection. Noncompliance may result in waiver termination or other licensing actions.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Inspection Report — Jul 10, 2024
Renewal
Date: Jul 10, 2024
Visit Reason
The inspection was conducted as a renewal and complaint investigation visit to review compliance and verify the submitted plan of correction.
Findings
The inspection identified multiple deficiencies including failure to conduct monthly fire drills, incomplete or missing medical evaluations, medication storage and administration issues, improper documentation, and missing signage for key-locking devices. Plans of correction were accepted and implemented with ongoing audits and staff retraining.
Citations (16)
An unannounced fire drill was not held during the months of May 2023, September 2023 and December 2023.
Resident 1 had not had an initial medical evaluation completed within required timeframes.
Resident 2’s most recent medical evaluation was not completed annually as required.
Prescription medications, OTC medications, CAM and syringes were found unlocked, unattended, and accessible in residents' medicine cabinets.
Expired medications were found in Resident 1's medicine cabinet.
Medications prescribed for residents were not available in the home as ordered.
Discrepancies were found between documented blood sugar readings on MAR and resident glucometer readings.
Medication administration records (MAR) did not match pharmacy labels regarding frequency of administration.
Resident refusals of medications were not documented or reported to prescribers as required.
Medications were not administered as ordered by the prescriber on multiple occasions.
Chemical restraint medications were prescribed without proper documentation and clarification.
Resident 1’s preadmission screening form did not include a determination that the resident's needs could be met by the home.
Resident 1’s initial assessment was not completed within 15 days of admission.
Resident 5’s cognitive preadmission screening was not completed within 72 hours prior to admission to the Secure Dementia Care Unit.
Directions for operating key-locking devices were not conspicuously posted near exits in the Secure Dementia Care Unit.
Privacy coding containing resident names was posted in a common area of the home.
Report Facts
Residents Served: 35
Memory Care Residents Served: 11
Current Hospice Residents: 7
Total Daily Staff: 46
Waking Staff: 35
Residents Age 60 or Older: 35
Residents with Mobility Need: 11
Inspection Report — Jan 3, 2024
Follow-Up
Date: Jan 3, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the submitted plan of correction related to resident abuse reporting, notification, and final incident reporting. Continued compliance must be maintained.
Citations (4)
Failure to immediately report suspected abuse of a resident to the area agency on aging, with a delay of more than 24 hours.
Failure to immediately notify the resident's designated person of a report of suspected abuse or neglect involving the resident.
Failure to submit a final report to the Department following the conclusion of an abuse investigation.
Resident was verbally and physically abused by staff, including yelling and grabbing the resident's wrist and upper arm.
Report Facts
Residents Served: 37
Secured Dementia Care Unit Residents Served: 16
Hospice Residents: 4
Total Daily Staff: 54
Waking Staff: 41
Residents with Mobility Need: 17
Inspection Report — May 16, 2023
Renewal
Date: May 16, 2023
Visit Reason
The inspection was conducted as a renewal review of the facility's license on 05/16/2023 and 05/17/2023 to determine compliance with regulatory requirements.
Findings
The facility was found to have multiple deficiencies including issues with posting current licenses, incident reporting delays, unsigned resident contracts, privacy violations related to electronic devices, unsecured poisonous materials, uncovered trash receptacles, ventilation problems, water leaks, inadequate lighting, missing emergency procedure submissions, expired rabies vaccination for a pet, delayed fire safety inspections, evacuation drill timing issues, incomplete resident medical evaluations, medication storage and availability problems, and missing official death certificates. Plans of correction were accepted and implemented with ongoing audits and retraining scheduled.
Citations (16)
The home's current violation reports dated 2/15/2022 and 5/18/2022 were not posted in a conspicuous and public place in the home.
The home did not report a resident's death incident to the Department until 4 days later.
Resident-home contracts for two residents were not signed by the residents and no notation was made indicating the opportunity to sign was given.
Facility-owned voice-controlled electronic device was used without policies, procedures, or notification posted regarding its use.
Poisonous materials were unlocked and accessible to residents in the Secured Dementia Care Unit laundry room.
An uncovered trash can was observed in a shared bathroom between Resident Rooms 214 and 202.
Men’s and women’s public bathrooms and a resident bathroom did not have operable ventilation fans or windows.
Active water leak under the women's public bathroom sink created a slipping hazard and water damage on floor.
Resident #5 did not have access to a source of light that can be turned on/off at bedside.
Written emergency procedures were not documented as submitted to the local emergency management agency.
A canine present at the home did not have a current rabies vaccination certificate; expired on 9/14/2022.
Fire safety inspection was not conducted annually; last done on 2/16/2022 and then on 4/13/2023.
Fire drills on 3/26/2023 and 4/26/2023 exceeded the maximum safe evacuation time of 6 minutes.
Resident #2's most recent medical evaluation was completed on 1/31/2023; previous was on 1/7/2022.
Medications prescribed as needed were not available in the home at the time of inspection.
Resident #4's record did not include a copy of the official death certificate.
Report Facts
Residents Served: 38
Residents Served in Secured Dementia Care Unit: 17
Current Hospice Residents: 6
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 18
Residents with Physical Disability: 0
Fire Drill Evacuation Time: 730
Fire Drill Evacuation Time: 401
Inspection Report — May 18, 2022
Follow-Up
Date: May 18, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 05/18/2022 to review the implementation of a previously submitted plan of correction related to an incident.
Complaint Details
The visit was complaint-related due to an incident involving alleged resident abuse by Staff Member A on 5/14/22 at 10:00pm. The abuse was witnessed by Staff Member B who delayed reporting until the following day. The incident was reported to DHS and the Area Office on Aging. Repeat violations were noted from prior years.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing multiple deficiencies including resident abuse, staff qualifications, emergency telephone postings, medication administration documentation, and confidentiality of resident records. Continued compliance and ongoing monitoring were emphasized.
Citations (5)
Resident abuse incident involving Staff Member A aggressively handling Resident A by pulling down pants and ripping shirt off, with failure to immediately report by Staff Member B.
Direct Care Staff Member A hired without a valid high school diploma or GED equivalent.
Emergency telephone numbers were not posted near a working telephone in Resident A's room in the secured dementia care unit.
Medication Administration Record did not indicate medication was given on 5/15/22 at 06:00am for Resident A.
Resident records were left unsecured and accessible in the wellness office and medication cart area.
Report Facts
Residents Served: 35
Residents Served in Dementia Unit: 13
Hospice Residents: 3
Residents with Mental Illness: 2
Residents with Mobility Need: 13
Residents 60 Years or Older: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member A | Named in resident abuse incident and subsequent disciplinary actions; no longer employed by the community. | |
| Staff Member B | Witnessed resident abuse incident but did not immediately report it. | |
| Staff Member C | Received delayed abuse report from Staff Member B and faxed incident report to DHS and Area Office on Aging. | |
| Staff Member D | Confirmed contents of unsecured resident record binders found unattended. |
Inspection Report — Feb 15, 2022
Renewal
Date: Feb 15, 2022
Visit Reason
The inspection was a renewal inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 02/15/2022 and 02/16/2022 to assess compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including delayed fire safety orientation for new staff, exceeding evacuation drill time, expired vehicle inspection, improper medication storage, uncalibrated glucometer, incomplete medical evaluations and preadmission screenings for secured dementia care unit residents, missing resident-home contract addendum, failure to timely report resident abuse and incidents, and missing conspicuous posting of lock operation instructions. Plans of correction were accepted for all deficiencies with specified completion dates.
Citations (11)
Staff persons did not receive orientation on general fire safety and emergency preparedness on their first day of work.
The home exceeded the maximum safe evacuation time of six minutes during a fire drill, recording ten minutes.
The state vehicle inspection for the 2012 Ford bus expired on 1/31/22.
Expired medication (Novolog pen) was stored in the medication cart beyond the discard date of 28 days after opening.
The glucometer used to check blood glucose was not calibrated to the correct date, showing a date of 3/19 instead of 2/16/22.
Resident #1's medical evaluation indicating the need for secured dementia care unit placement was completed after admission.
Resident #1's written cognitive preadmission screening was completed after admission to the secured dementia care unit.
Resident-home contract including disclosures specific to the secured dementia care unit was not completed for Resident #1, nor was there an addendum to the prior contract.
Failure to immediately report suspected resident-to-resident abuse occurring on 2/11/22 until 2/15/22 when licensing staff inquired.
Failure to report a fall incident on 8/6/21 resulting in hospitalization to the Department.
Directions for operating the home's locking mechanism were not conspicuously posted near the courtyard gate.
Report Facts
Residents Served: 27
Residents Served in Secured Dementia Care Unit: 9
Hospice Residents: 3
Residents with Mobility Need: 10
Residents Diagnosed with Mental Illness: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Named in medication storage, glucometer calibration, abuse reporting, incident reporting, and medication audit findings | |
| Executive Director | Named in multiple findings including fire safety training, evacuation drill, vehicle inspection, medical evaluation, preadmission screening, resident-home contract, abuse reporting, incident reporting, and lock code signage | |
| Associate Executive Director | Named in fire safety training, medical evaluation, preadmission screening, and resident-home contract findings | |
| Maintenance Technician | Named in fire safety training and evacuation drill findings | |
| Maintenance Manager | Named in vehicle inspection scheduling and audit | |
| Sales Manager | Named in resident-home contract documentation retraining | |
| Clare Bridge Program Coordinator | Named in lock code signage posting and audit |
Inspection Report — Dec 22, 2021
Routine
Date: Dec 22, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Notice — Oct 20, 2021
Date: Oct 20, 2021
Visit Reason
The document serves as a renewal notification and certificate of compliance for the Personal Care Home 'Brookdale Harrisburg'. It informs the facility that an onsite inspection will be conducted within the next twelve months as required by state regulations.
Findings
No inspection findings are reported in this document. It confirms issuance of a regular license following the renewal application and advises that future inspections will be conducted to ensure compliance.
Report Facts
Inspection Report — Jan 19, 2021
Routine
Date: Jan 19, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Notice — Dec 3, 2020
Date: Dec 3, 2020
Visit Reason
This document serves as a license renewal notification and certificate of compliance for Brookdale Harrisburg Personal Care Home. It informs the facility that an annual onsite inspection will be conducted within the next twelve months as required by state regulations.
Findings
The Department has issued a regular license in response to the renewal application. No findings or deficiencies are reported in this document.
Report Facts
Inspection Report — Apr 23, 2020
Complaint Investigation
Date: Apr 23, 2020
Visit Reason
The inspection was conducted as a complaint investigation following allegations of suspected sexual abuse and failure to report an incident involving residents.
Complaint Details
The complaint involved suspected sexual abuse of Resident #1 and failure to report a fall incident involving Resident #2. The sexual abuse allegation was unsubstantiated. The facility failed to report the fall incident timely and did not adequately investigate a complaint related to Resident #1's fall.
Findings
The investigation found that the facility did not immediately report suspected abuse as required and failed to provide adequate measures to resolve a complaint related to a resident's fall. The allegation of sexual abuse was determined to be unsubstantiated after investigation.
Citations (3)
Regulation 2600.15.a: The home did not immediately report suspected abuse of Resident #1 as required by the Older Adult Protective Services Act.
Regulation 2600.16.c: The home failed to report a fall incident involving Resident #2 to the Department until May 1, 2020, despite the fall occurring on April 13, 2020.
Regulation 44.d: The home did not ensure proper investigation and resolution of a complaint regarding Resident #1's fall and lack of staff response, including failure to return a visitor's call and notify managers.
Report Facts
Residents Served: 45
Dementia Unit Residents Served: 16
Resident with Mental Illness: 3
Residents Age 60 or Older: 41
Residents with Mobility Need: 20
Resident Support Staff: 65
Waking Staff: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Jacobs | Executive Director | Named in relation to plan of correction approval and oversight of complaint investigation |
Inspection Report — Oct 30, 2019
Renewal
Date: Oct 30, 2019
Visit Reason
The inspection was conducted as a renewal inspection with an incident review for Brookdale Harrisburg on October 30, 2019 and November 18, 2019.
Findings
The submitted plan of correction was found to be fully implemented. Deficiencies included failure to post Chapter 2600 regulations and weekly menus in the Secured Dementia Care Unit, and failure to post the operation code for the courtyard door. Corrective actions involved staff retraining, weekly audits, and executive review.
Citations (3)
A copy of the Chapter 2600 regulations was not posted in a conspicuous and public place in the Secured Dementia Care Unit.
The home's weekly menus were not posted in the Secured Dementia Care Unit.
The operation code for the door to the courtyard in the secure dementia unit was not conspicuously posted.
Report Facts
Residents Served: 46
Secured Dementia Care Unit Residents Served: 18
Hospice Current Residents: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Jacobs | Executive Director | Signed plan of correction and noted in corrective action steps |
Inspection Report — Sep 30, 2019
Renewal
Date: Sep 30, 2019
Visit Reason
This document is a renewal application and license issuance for Brookdale Harrisburg Personal Care Home, confirming the facility's authorization to operate under Title 55, PA Code, Chapter 2600.
Findings
The Department has approved the renewal application and issued a regular license for Brookdale Harrisburg. The Department will conduct an onsite annual inspection within the next twelve months to ensure compliance with applicable laws and regulations.
Report Facts
Inspection Report — Dec 17, 2018
Annual Inspection
Date: Dec 17, 2018
Visit Reason
The inspection was an annual licensing inspection conducted on December 17 and 18, 2018, to assess compliance with 55 Pa.Code Chapter 2600 relating to Personal Care Homes.
Findings
Several violations were found including failure to submit a plan of supervision for a staff person alleged of abuse, presence of undated and unlabeled food items, outdated or spoiled food in the Secure Dementia Unit, and incomplete support plans for a resident. Plans of correction were submitted and partially implemented as of January 7, 2019.
Citations (4)
Regulation 55 Pa.Code §2600.15(c): The home failed to immediately submit a plan of supervision or notice of suspension for a staff person involved in an abuse allegation until 12/18/2018.
Regulation 55 Pa.Code §2600.103(e): An undated and unlabeled plastic container of pie and a container of eggs and beets were found in the Secure Dementia Unit dining room/kitchenette.
Regulation 55 Pa.Code §2600.103(i): Outdated or spoiled food including a 0.58 lb paper package of raw chicken and a 2 lb container of yogurt were located in the Secure Dementia Unit refrigerator.
Regulation 55 Pa.Code §2600.234(d): The support plan for Resident 2 did not document the home's plan to meet care needs related to pressure wounds, body weight measurements, heart disease diagnosis, and daily blood pressure measurements.
Report Facts
Number of Residents Served: 44
Number of Residents Served in Secured Dementia Care Unit: 15
Number of Current Hospice Residents: 6
Number of Hospice Residents in Past Year: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Jacobs | Administrator | Named as Administrator and Legal Entity Representative signing the violation report and plan of correction. |
| Laura Heemer | Department Representative | Listed as Department Representative on-site during inspection. |
| Hope OPake | Department Representative | Listed as Department Representative on-site during inspection. |
Inspection Report — May 8, 2018
Renewal
Date: May 8, 2018
Visit Reason
The inspection was conducted as an annual renewal inspection of the Brookdale Harrisburg Personal Care Home facility on May 8, 2018 and July 3, 2018.
Findings
The inspection identified multiple violations related to sanitary conditions, blood glucose monitoring procedures, hot water temperature, and safe storage and access of medications and medical equipment. Plans of correction were submitted addressing these issues with varying levels of implementation progress.
Citations (3)
Regulation 2600.85(a): Sanitary conditions were not maintained as blood glucose readings were improperly recorded and shared glucometer use was observed.
Regulation 2600.89(b): Hot water temperature in the bathroom of Room 103 measured 123 degrees Fahrenheit, exceeding the 120-degree limit.
Regulation 2600.185(a): The home failed to implement procedures for safe storage, access, security, distribution, and use of medications and medical equipment by trained staff.
Report Facts
Number of Residents Served: 40
Fine Amount: 200
Correction Deadline: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Samantha Sipe | Executive Director | Named as legal entity representative and involved in plan of correction signatures and responses. |
| Jacqueline L. Rowe | Director | Signed enforcement letter on page 3. |
Inspection Report — Feb 27, 2018
Renewal
Date: Feb 27, 2018
Visit Reason
The document is a renewal license issued to Brookdale Harrisburg for operating a Personal Care Home. The Department of Human Services notifies that an onsite inspection will be conducted within the next twelve months as part of the annual inspection requirement.
Findings
No inspection findings are reported in this document. It serves as a license renewal certificate and notification of upcoming inspection requirements.
Report Facts
Inspection Report — Nov 20, 2017
Complaint Investigation
Date: Nov 20, 2017
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident on November 20, 2017, involving suspected physical abuse between residents at Brookdale Harrisburg.
Complaint Details
The complaint investigation was substantiated. An incident of physical aggression between residents was confirmed, and the facility failed to report it and update assessments accordingly.
Findings
The facility failed to immediately report an incident of physical aggression between residents and did not update resident assessments to reflect changes in behavior. Additionally, a resident admitted to the secured dementia care unit did not have a timely medical evaluation or preadmission screening completed.
Citations (4)
Regulation 2600.15(a): The home did not immediately report suspected abuse of a resident as required by the Older Adults Protective Services Act.
Regulation 2600.225(c): Resident assessments for two residents involved in a physical altercation were not updated sufficiently to reflect changes in aggression levels.
Regulation 2600.231(b): A resident admitted to the secured dementia care unit did not have a medical evaluation completed within 60 days prior to admission.
Regulation 2600.231(c): A resident admitted to the secured dementia care unit did not have a preadmission screening completed within 72 hours prior to admission.
Report Facts
Number of Residents Present: 31
Number of Current Hospice Residents: 3
Number of Residents 60 Years or Older: 54
Number of Residents with Mobility Need: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Samantha Sipe | Executive Director | Named in multiple plans of correction related to retraining staff and policy implementation. |
| Michael Showers | Department representative on-site during inspection. |
Inspection Report — May 31, 2017
Renewal
Date: May 31, 2017
Visit Reason
The inspection was conducted as part of the Adult Residential Licensing's annual licensing inspection and included renewal and complaint reasons.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 related to Personal Care Homes were found, including issues with resident record confidentiality, staffing for first aid and CPR, sanitary conditions, medication administration, menu posting, wound care, and support plan documentation.
Citations (7)
Regulation 2600.17 - Resident records were found unattended and accessible in the dining room, exposing confidential resident information.
Regulation 2600.63(a) - Only one staff member with current first aid and CPR certification was present despite more than 50 residents being in the home.
Regulation 2600.85(a) - Blood sugar testing records for residents were inconsistent and a shared glucometer was used without proper procedures.
Regulation 2600.162(c) - The only menu posted was for one week, not the required weekly menus posted one week in advance.
Regulation 2600.187(d) - Medication orders and administration for wound care and blood sugar checks were not followed according to physician's orders.
Regulation 2600.227(g) - Resident did not sign support plans developed on specified dates.
Regulation 2600.224(a) - Pre-admission screening forms for residents did not include determinations that the home could meet the residents' service needs.
Report Facts
Number of Residents Served: 55
Number of Residents Served: 53
Number of Current Hospice Residents: 3
Number of Current Hospice Residents: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Samantha Sipe | Executive Director | Named in relation to multiple findings and plans of correction throughout the report. |
Inspection Report — Feb 17, 2017
Renewal
Date: Feb 17, 2017
Visit Reason
This document is a renewal application and license issuance for Brookdale Harrisburg Personal Care Home. The Department notifies that an onsite inspection will be conducted within the next twelve months as part of the annual inspection requirement.
Findings
No inspection findings are reported in this document. It serves as a license renewal confirmation and notification of future inspection requirements.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline L. Rowe | Director | Signed the renewal notification letter |
Inspection Report — Jun 21, 2016
Renewal
Date: Jun 21, 2016
Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing renewal inspections on June 21 and June 22, 2016, for Brookdale Harrisburg Personal Care Home.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found related to posting of inspection reports, emergency phone numbers, operable lighting in resident rooms, use of portable space heaters, fire drill documentation, medication administration records, and pre-admission screenings. Plans of correction were submitted and approved with most corrections fully implemented or in progress.
Citations (7)
Regulation 2600.3(c): The most recent violation report from 2015 was not posted in the home as required.
Regulation 2600.91: Telephone numbers for emergency services were not posted at the telephone in the library and resident rooms #311 and #333.
Regulation 2600.101(7): The bed in bedroom #200 of the secure dementia unit lacked an operable lamp or other source of lighting at the bedside.
Regulation 2600.127(a): A portable space heater was found in resident room #311, which is prohibited.
Regulation 2600.132(c): Fire drill records did not include the designation of AM or PM for drills conducted on 10/28/2015, 11/4/2015, and 1/21/2016.
Regulation 2600.187(a): The medication administration record for resident #1 did not match the actual prescription for Finasteride 5mg, which was given as half a tablet daily instead of one tablet.
Regulation 2600.224(a): Preadmission screenings for residents #2 and #3 were not completed on the Department's preadmission screening form.
Report Facts
Number of Residents Served: 55
Number of Current Hospice Residents: 4
Number of Hospice Residents in past year: 8
Number of Residents 80 Years or Older: 55
Number of Residents with Mental Illness: 2
Number of Residents with Mobility Need: 34
Number of Residents with Physical Disability: 4
Number of Residents Served in Secured Dementia Care Unit: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brian Hofsass | Executive Director | Named as Executive Director and signer of plans of correction. |
| Jay Bausch | Deputy Secretary | Signed the cover letter for the inspection report. |
| Cybil Bomberger | Department of Human Services inspector conducting the inspection. | |
| Michael Showers | Department of Human Services inspector conducting the inspection. |
Notice — Mar 22, 2016
Date: Mar 22, 2016
Visit Reason
This document serves as a renewal notification and license issuance for Brookdale Harrisburg Personal Care Home, confirming the facility's authorized capacity and informing about the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It is a license renewal notice with a certificate of compliance.
Report Facts
Inspection Report — Feb 19, 2016
Enforcement
Date: Feb 19, 2016
Visit Reason
The Department of Human Services issued a notice of intent to assess a fine for regulatory violations related to advertising as an assisted living residence when the facility is a personal care home.
Findings
Brookdale Harrisburg was found to be advertising assisted living services without proper licensure as an assisted living residence. The facility was fined $2,295 for this violation and required to correct all advertising materials to comply with Pennsylvania regulations.
Citations (1)
55 Pa.Code § 2600.18: The facility advertised assisted living services without being licensed as an assisted living residence. Brookdale Harrisburg is a personal care home but used the term 'assisted living' in advertising.
Report Facts
Fine per resident per day: 3
Total fine amount: 2295
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacob Herzing | Enforcement Manager | Named as contact for appeals and inspection. |
| Matthew J. Jones | Director | Signed enforcement letter. |
| Kevin Brumbach | Human Services Licensing Contact | Contact for invoice questions. |
Inspection Report — Jan 29, 2016
Date: Jan 29, 2016
Visit Reason
The inspection was conducted as an interim document review related to enforcement of licensing regulations concerning the improper use of the term 'Assisted Living' by Brookdale Harrisburg.
Findings
The facility was found to be in violation of 55 Pa.Code § 2600.18 for advertising assisted living services without being a licensed assisted living residence. A fine was proposed based on the census of 51 residents until the violation is corrected.
Citations (1)
55 Pa.Code § 2600.18: The facility advertised assisted living services without being licensed as an assisted living residence, violating state regulations.
Report Facts
Fine per resident per day: 3
Calculated Fine per day: 153
Mandated Correction Date: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matthew J. Jones | Director | Signed letter explaining violation and enforcement |
| Jacob Herzing | Enforcement Manager | Contact for submission of plan of correction and off-site inspection |
Notice — December 10, 2025
Date: December 10, 2025
Visit Reason
This document serves as an invoice for fines assessed to Brookdale Harrisburg related to violations of 55 PA Code § 2600.
Findings
The invoice details two fines classified as Class III and Class II violations with respective amounts of $2,880.00 and $4,800.00, totaling $7,680.00 due.
Report Facts
Fine amount: 2880
Fine amount: 4800
Total fine amount: 7680
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