Inspection Report
Renewal
Census: 40
Capacity: 65
Deficiencies: 31
Jul 8, 2025
Visit Reason
The inspection was a full, unannounced renewal inspection with an incident reason, conducted over multiple days in July 2025 to assess compliance with regulations for the Personal Care Home facility.
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 issues with facility maintenance and safety. Plans of correction were accepted for all deficiencies with follow-up audits scheduled.
Deficiencies (31)
| Description |
|---|
| Resident #2 medication error was not reported to the Department within 24 hours. |
| Resident #1 was neglected and abused, with failure to provide proper wound care and timely checks. |
| Failure to complete written initial assessment and preadmission screening for resident #1. |
| Failure to follow prescriber's orders for multiple residents, including missed medications. |
| Failure to provide immediate access to Department agents and requested records. |
| Failure to immediately report suspected resident abuse. |
| Resident records were not kept confidential; resident information was accessible on medication cart. |
| 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. |
| Unlabeled poisonous materials found in Secure Dementia Care Unit (SDCU) and laundry room. |
| Poisonous materials not locked and accessible to residents in multiple SDCU rooms. |
| Damaged furniture and malfunctioning toilet in resident areas; heavy bathroom doors posing hazard. |
| Unlabeled, undated, and unsealed food stored in protein freezer. |
| Lint accumulation in dryer lint trap in laundry room. |
| Exit doors blocked by objects, obstructing egress routes. |
| Fire drill records incomplete, missing key information such as exit routes, number of residents evacuated, and alarm status. |
| Residents #6 and #7 had overdue annual medical evaluations. |
| Medications and syringes were unlocked and accessible in resident rooms for residents unable to self-administer. |
| Medications not stored properly; damaged blister packs and missing PRN medications. |
| OTC medication Claritin not labeled with resident's name. |
| Discrepancies between glucometer readings and medication administration records; missing medications in home. |
| Medication refusals by residents were not reported to prescribers within 24 hours. |
| Failure to follow prescriber's orders due to unavailable medications. |
| Staff person administered insulin without completing required diabetes education program. |
| Residents #6 and #7 had overdue additional assessments. |
| Support plans for residents #6, #7, #8, and #9 lacked required signatures. |
| Resident #9's initial medical evaluation was completed after admission to the Secure Dementia Care Unit. |
| No documentation that resident #8 and designated person did not object to admission to Secure Dementia Care Unit. |
| Directions for operating key-locking devices were not conspicuously posted near Secure Dementia Care Unit exits. |
| Resident #8's admission support plan was completed after admission to Secure Dementia Care Unit. |
| Staff persons E and F working in Secure Dementia Care Unit had insufficient dementia care training hours for 2024. |
Report Facts
License Capacity: 65
Residents Served: 40
Residents in Secure Dementia Care Unit: 8
Staffing Hours: 61
Waking Staff: 46
Fines: 760
Inspection Dates: 4
Inspection Report
Renewal
Census: 40
Capacity: 65
Deficiencies: 26
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.
Deficiencies (26)
| Description |
|---|
| 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
License Capacity: 65
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). |
Inspection Report
Renewal
Census: 35
Capacity: 65
Deficiencies: 16
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.
Deficiencies (16)
| Description |
|---|
| 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
License Capacity: 65
Residents Served: 35
Memory Care Capacity: 24
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
Follow-Up
Census: 37
Capacity: 65
Deficiencies: 4
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.
Deficiencies (4)
| Description |
|---|
| 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
License Capacity: 65
Residents Served: 37
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 16
Hospice Residents: 4
Total Daily Staff: 54
Waking Staff: 41
Residents with Mobility Need: 17
Inspection Report
Renewal
Census: 38
Capacity: 65
Deficiencies: 16
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.
Deficiencies (16)
| Description |
|---|
| 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
License Capacity: 65
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
Follow-Up
Census: 35
Capacity: 65
Deficiencies: 5
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.
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.
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.
Deficiencies (5)
| Description |
|---|
| 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
License Capacity: 65
Residents Served: 35
Secured Dementia Care Unit Capacity: 24
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
Renewal
Census: 27
Capacity: 65
Deficiencies: 11
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.
Deficiencies (11)
| Description |
|---|
| 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
License Capacity: 65
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
Routine
Deficiencies: 0
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
Capacity: 65
Deficiencies: 0
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
Maximum licensed capacity: 65
Secure Dementia Care Unit capacity: 24
Inspection Report
Routine
Deficiencies: 0
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.
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