Inspection Report
Complaint Investigation
Census: 63
Capacity: 88
Deficiencies: 5
Jun 4, 2025
Visit Reason
The inspection was an unannounced partial complaint investigation conducted on 06/04/2025 to review compliance with regulations following a complaint.
Findings
The inspection found multiple deficiencies including medication errors with improper administration times and failure to report errors, obstructed egress due to energized magnetic locks, staff not completing required medication administration training, and missing current resident photographs in records. Plans of correction were accepted and implemented by 07/08/2025.
Complaint Details
The visit was complaint-related as indicated by the inspection reason. The submitted plan of correction was determined to be fully implemented as of 06/04/2025.
Deficiencies (5)
| Description |
|---|
| Medication errors where prescribed medications were administered before the prescribed times and not reported to the Department. |
| Magnetic locks on exit doors and exterior gates were energized and prevented egress from the home. |
| Medications were administered by a staff person who had not completed the Department-approved medication administration course within the past year. |
| Medication errors were not reported to the prescriber as required. |
| Resident records did not include a current photograph of the resident. |
Report Facts
Residents served: 63
License capacity: 88
Total daily staff: 63
Waking staff: 47
Current hospice residents: 3
Medication errors: 3
Inspection Report
Follow-Up
Census: 63
Capacity: 88
Deficiencies: 4
Apr 15, 2025
Visit Reason
The inspection visit was a partial, unannounced follow-up to verify the implementation of a previously submitted plan of correction related to an incident.
Findings
The facility was found to have fully implemented the plan of correction related to an abuse incident and other deficiencies including unobstructed egress, additional resident assessments, and support plan documentation. Continued compliance and ongoing education were emphasized.
Deficiencies (4)
| Description |
|---|
| Resident was subjected to inappropriate physical contact despite verbal refusal, constituting abuse. |
| Egress doors to fenced courtyard were locked and would not open, obstructing safe exit. |
| Resident's assessment was not updated to reflect significant changes in condition including swallowing difficulties and dementia progression. |
| Resident's support plan was not updated to document the use of a Wanderguard system. |
Report Facts
License Capacity: 88
Residents Served: 63
Staffing Hours: 63
Waking Staff: 47
Secured Dementia Care Unit Capacity: 18
Current Hospice Residents: 4
Residents Age 60 or Older: 63
Residents Receiving Supplemental Security Income: 1
Inspection Report
Renewal
Census: 65
Capacity: 88
Deficiencies: 7
Nov 5, 2024
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements and to verify the submitted plan of correction was fully implemented.
Findings
The inspection identified several deficiencies related to first aid kit contents, medication storage and labeling, medication administration documentation, and resident assessments. The facility submitted plans of correction for all deficiencies, which were accepted and later implemented.
Deficiencies (7)
| Description |
|---|
| The first aid kit in the Grey Ford Taurus used to transport residents did not include scissors. |
| Two loose pills were observed in the north hallway medication cart drawer. |
| Medication labeling discrepancy: directions on the medication administration record differed from the pharmacy label. |
| PRN medications prescribed to a resident were not available in the home. |
| Medication administration documentation was incomplete or incorrect for oxygen administration orders on multiple dates and shifts. |
| Resident initial assessments were not completed within 15 days of admission for some residents. |
| Resident transferred from Secure Dementia Care Unit (SDCU) to personal care had an outdated assessment indicating need for SDCU services. |
Report Facts
License Capacity: 88
Residents Served: 65
Medication Cart Audits: 55
Staffing Hours: 65
Waking Staff: 49
Secure Dementia Care Unit Capacity: 18
Current Residents in Hospice: 4
Residents Age 60 or Older: 65
Residents with Supplemental Security Income: 1
Residents Diagnosed with Mental Illness: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in medication storage, labeling, and administration documentation findings and corrective actions |
| Assistant Director of Nursing | Assistant Director of Nursing | Involved in medication storage, labeling, and administration documentation findings and corrective actions |
| Campus Executive Director | Campus Executive Director | Responsible for ensuring ongoing compliance and education related to deficiencies |
| Lead Driver | Lead Driver | Responsible for replacing scissors in first aid kit and conducting audits |
Inspection Report
Renewal
Census: 61
Capacity: 88
Deficiencies: 7
Dec 6, 2023
Visit Reason
The inspection was an unannounced full renewal inspection with an incident review conducted on 12/06/2023.
Findings
The inspection identified multiple deficiencies including abuse, unsecured poisonous materials, lint accumulation in dryer, medication labeling errors, incomplete support plans, incomplete medication administration course completion, and improper handling of resident records. Plans of correction were accepted and implemented by 12/28/2023.
Deficiencies (7)
| Description |
|---|
| Staff member placed hands down resident's pants to check if needed to be changed, constituting abuse. |
| Poisonous materials were unlocked, unattended, and accessible to residents in the secured dementia care unit. |
| Approximately 2 inch accumulation of lint in the lint trap of dryer #1 in the main laundry room. |
| Medication container label did not reflect the changed dosage and instructions for administration. |
| Cognitive behavioral section of the assessment/support plan for Resident 2 was not completed. |
| Staff person without successful completion of Department-approved medication administration course administered medications. |
| Residents' privacy code information from license inspection summaries was posted in the home, violating confidentiality. |
Report Facts
Residents Served: 61
License Capacity: 88
Secured Dementia Care Unit Capacity: 18
Secured Dementia Care Unit Residents Served: 13
Hospice Current Residents: 5
Residents Age 60 or Older: 61
Residents with Mobility Need: 13
Inspection Report
Complaint Investigation
Census: 64
Capacity: 88
Deficiencies: 0
Jun 15, 2023
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 06/15/2023.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Report Facts
License Capacity: 88
Residents Served: 64
Secured Dementia Care Unit Capacity: 18
Secured Dementia Care Unit Residents Served: 14
Current Hospice Residents: 2
Resident Count with Mental Illness: 26
Resident Count Age 60 or Older: 64
Resident Count with Intellectual Disability: 1
Resident Count with Mobility Need: 14
Resident Count with Physical Disability: 0
Inspection Report
Follow-Up
Census: 58
Capacity: 88
Deficiencies: 1
Mar 7, 2023
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 a failure to report an allegation of sexual abuse. Continued compliance must be maintained.
Deficiencies (1)
| Description |
|---|
| The home was made aware of an allegation of sexual abuse involving a resident but did not report the allegation to the Pennsylvania Department of Aging. |
Report Facts
License Capacity: 88
Residents Served: 58
Secured Dementia Care Unit Capacity: 18
Secured Dementia Care Unit Residents Served: 13
Hospice Current Residents: 4
Residents Receiving Supplemental Security Income: 2
Residents 60 Years or Older: 58
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Resident Services | Made the report via telephone to the Pennsylvania Department of Aging on 3/17/2023 | |
| Campus Executive Director | Retrained managers on proper abuse reporting and reviewed abuse reporting forms |
Inspection Report
Renewal
Census: 65
Capacity: 88
Deficiencies: 12
Jan 24, 2023
Visit Reason
The inspection was a renewal inspection conducted to review compliance with licensing regulations and to verify the implementation of the submitted plan of correction.
Findings
The inspection found multiple deficiencies including failure to post the last renewal inspection report, insufficient staff with current CPR/First Aid certification during night shifts, unlocked poisonous materials accessible to residents, uncovered trash dumpsters, hot water temperature exceeding limits, missing emergency phone numbers, obstructed egress, overdue fire drill during sleeping hours, improper medication storage and labeling, incomplete support plan documentation, and unsecured resident records. All deficiencies had plans of correction accepted and were reported as implemented by the dates indicated.
Deficiencies (12)
| Description |
|---|
| Last renewal inspection report was not posted in a conspicuous and public place in the home. |
| Insufficient staff with current certification in first aid and CPR during night shifts on 1/12/23, 1/13/23, and 1/14/23. |
| Poisonous materials (Clorox Health Care Wipes) were unlocked and accessible to residents in the secure dementia care unit. |
| Trash dumpsters outside the home were partially full with sliding side doors open, not preventing insect and rodent penetration. |
| Hot water temperature at bathroom sink in bedroom 22 measured 123.4°F, exceeding the 120°F limit. |
| Emergency telephone numbers for nearest hospital and fire department were missing on or near a resident's telephone. |
| Four dining room chairs blocked egress from the home's dining room on the outside patio. |
| Fire drill during sleeping hours was not conducted within the required 6-month timeframe. |
| Loose blue and white tablet marked '600' found in the north hallway medication cart. |
| Prescription label was torn off a jar of Major brand Minerin Cream; no resident name present. |
| Support plan did not include notation of resident's refusal or inability to sign. |
| Binders containing residents' prescription information were stored unlocked and accessible on medication carts. |
Report Facts
License Capacity: 88
Residents Served: 65
Residents in Secured Dementia Care Unit: 14
Residents in Hospice: 5
Residents with Mobility Need: 25
Residents 60 Years or Older: 65
Residents Receiving Supplemental Security Income: 3
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Intellectual Disability: 0
Total Daily Staff: 90
Waking Staff: 68
Residents Present During CPR Deficiency: 60
Date of Last Fire Drill During Sleeping Hours: Jul 28, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in relation to medication storage, labeling, and staff training deficiencies. |
| Assistant Director of Nursing | ADON | Named in relation to medication storage, labeling, and staff training deficiencies. |
| Unit Manager | Unit Manager | Named in relation to locking poisonous materials, emergency phone numbers, egress obstruction, and staff re-education. |
| Maintenance Director | Maintenance Director | Named in relation to trash dumpster lid closure and water temperature monitoring. |
| Campus Executive Director | Campus ED | Named in relation to posting inspection reports, fire drill scheduling, and plan of correction oversight. |
| Talent Development Coordinator | Talent Development Coordinator | Named in relation to scheduling CPR and First Aid training. |
Inspection Report
Renewal
Capacity: 88
Deficiencies: 0
Jul 21, 2021
Visit Reason
The document is a renewal application response for the Ecumenical Community of Harrisburg Personal Care Home, confirming issuance of a regular license and advising that an annual inspection will be conducted within the next twelve months.
Findings
No inspection findings are reported in this document; it serves as a license renewal notification and outlines the requirement for a future annual inspection.
Report Facts
Maximum licensed capacity: 88
Inspection Report
Renewal
Census: 62
Capacity: 88
Deficiencies: 2
May 26, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license, with an unannounced full inspection on 05/26/2021 and 05/27/2021.
Findings
The inspection found two deficiencies: improper medication administration technique by a direct care staff member and incomplete documentation of a resident's use of a bed cane in the support plan. Both deficiencies were addressed with plans of correction that were accepted and fully implemented.
Deficiencies (2)
| Description |
|---|
| Direct Care Staff Person A was observed pouring medication from pill bottles into the staff person's ungloved hand and placing the medication in a pill cup for administration. |
| The need for a bed cane was not included in Resident 1's assessment and support plan. |
Report Facts
License Capacity: 88
Residents Served: 62
Current Hospice Residents: 6
Total Daily Staff: 64
Waking Staff: 48
Residents with Mobility Need: 2
Residents with Physical Disability: 1
Inspection Report
Renewal
Deficiencies: 0
Jan 5, 2021
Visit Reason
The inspection was conducted as part of licensing inspections by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 01/05/2021 and 01/14/2021 for the facility.
Findings
No regulatory citations were identified as a result of this inspection.
Loading inspection reports...
