Brookdale Harrisburg.

“Multiple bottles of prescription and OTC medications and syringes were found unlocked, unattended, and accessible in resident rooms (nightstands, rolling storage carts, bathrooms, and medicine cabinets) where residents were unable to self-administer medications.”

“Multiple OTC medications were found in resident rooms without current physician orders, including items in nightstands, rolling storage carts, bathrooms, and medicine cabinets.”

“Five residents had medications with pharmacy labels that did not match the prescribed dosage and administration instructions on the physician orders, including discrepancies in dosage amounts, frequency, and routes of administration.”

“An OTC medication bottle belonging to a resident was found in the medication cart without being labeled with the resident's name.”

“Prescribed as-needed medications for a resident were not available in the home at the time of inspection.”

“Prescribed medications for residents were not administered as ordered by the prescriber because the medications were not available in the home during the specified dates.”

“Class III violation cited with calculated fine of $120 per day (40 residents × $3 per resident per day) for violation identified during inspection.”

“Class II violation cited with calculated fine of $200 per day (40 residents × $5 per resident per day) for violation identified during inspection.”

“Class III violation cited with calculated fine of $120 per day (40 residents × $3 per resident per day) for violation identified during inspection.”

“Class II violation cited with calculated fine of $200 per day (40 residents × $5 per resident per day) for violation identified during inspection.”

“Class III violation cited with calculated fine of $120 per day (40 residents × $3 per resident per day) for violation identified during inspection.”

“Facility issued a FIRST PROVISIONAL license due to violations identified during inspections on June 16, 2025, July 8, 2025, July 9, 2025, and July 10, 2025. License valid from October 2, 2025 to April 2, 2026.”

“Resident #2 was prescribed a 6-day taper of Methylprednisolone tablets but was administered only 5 out of 6 pills on 3/24/25. The home did not report this medication error to the Department until 03/27/25, failing to report within 24 hours as required.”

“Resident #1 was admitted but the home failed to complete a written initial assessment and preadmission screening did not include determination that the home could meet the resident's needs. The resident developed a stage II gluteal ulcer requiring wound care. Despite home health instructions on 5/29/25 to use pressure-relieving devices and limit chair sitting to 2 hours, the home failed to acquire a pressure-relieving device. On 6/7/25, staff member B refused to check on or change the resident due to odor. By approximately 8:00 AM on 6/7/25, resident #1 was found soaked in urine and feces, leading to hospitalization for sepsis, pneumonia, and suspected necrotizing fasciitis. The resident died on an unspecified date while receiving hospice care.”

“Facility issued a FIRST PROVISIONAL license due to violations identified during inspections on June 16, 2025, July 8, 2025, July 9, 2025, and July 10, 2025. License valid from October 2, 2025 to April 2, 2026.”

“Resident #2 was prescribed a 6-day taper of Methylprednisolone tablets but was administered only 5 out of 6 pills on 3/24/25. The home did not report this medication error to the Department until 03/27/25, failing to report within 24 hours as required.”

“Resident #1 was admitted but the home failed to complete a written initial assessment and preadmission screening did not include determination that the home could meet the resident's needs. The resident developed a stage II gluteal ulcer requiring wound care. Despite home health instructions on 5/29/25 to use pressure-relieving devices and limit chair sitting to 2 hours, the home failed to acquire a pressure-relieving device. On 6/7/25, staff member B refused to check on or change the resident due to odor. By approximately 8:00 AM on 6/7/25, resident #1 was found soaked in urine and feces, leading to hospitalization for sepsis, pneumonia, and suspected necrotizing fasciitis. The resident died on an unspecified date while receiving hospice care.”

“Class III violation cited with calculated fine of $120 per day (40 residents × $3 per resident per day) for violation identified during inspection.”

“Class II violation cited with calculated fine of $200 per day (40 residents × $5 per resident per day) for violation identified during inspection.”

“Class III violation cited with calculated fine of $120 per day (40 residents × $3 per resident per day) for violation identified during inspection.”

“Class II violation cited with calculated fine of $200 per day (40 residents × $5 per resident per day) for violation identified during inspection.”

“Class III violation cited with calculated fine of $120 per day (40 residents × $3 per resident per day) for violation identified during inspection.”

“An unannounced fire drill was not held during the months of May 2023, September 2023 and December 2023.”

“Resident 1 was admitted to the home but has not had an initial medical evaluation completed within 60 days prior to admission or within 30 days after admission.”

“Resident 2's most recent medical evaluation was not completed within the required annual timeframe. This is a repeated violation from 05/16/2023.”

“Prescription and OTC medications and syringes were found unlocked, unattended, and accessible in resident rooms of Residents 1 and 4, who are not assessed to self-administer their medications.”

“Expired prescription and OTC medications were found stored in Resident 1's medicine cabinet, not stored in accordance with manufacturer's instructions and proper storage conditions.”

“Prescribed medications for Residents 1 and 2 were not available in the home when needed. Additionally, Resident 2 had multiple discrepancies between blood sugar readings documented in the medication administration record and the resident's glucometer. This is a repeated violation from 05/16/2023.”

“A staff person was observed yelling at and forcefully grabbing a resident. The allegation of abuse was not reported to the area agency on aging until 3:30 PM on 12/15/23, more than 24 hours after the incident occurred.”

“The home received a report of suspected abuse involving a resident but did not notify the resident's designated person of the allegation.”

“Allegations of physical and verbal abuse were reported to the Department. The home did not submit a final report to the Department following the conclusion of the investigation.”

“A staff person was observed yelling at and grabbing the left wrist and upper arm of a resident while attempting to take the resident to the bedroom.”