Pennsylvania Department of Health
COMPLETE CARE AT HARSTON HALL LLC
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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COMPLETE CARE AT HARSTON HALL LLC - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID# 080702
Component 01
Main Building

Based on an Abbreviated survey, as part of a complaint investigation conducted on October 6, 2025, and completed on October 8, 2025, it was determined that Complete Care at Harston Hall, LLC was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy.

This is a three-story, Type II (222), fire resistive building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345
Based on observation, document review, and interview, it was determined the facility failed to ensure the fire alarm system was maintained, affecting the entire facility.

Findings include:

1. Document review on October 6, 2025, at 9:45 a.m., revealed the System 2 fire alarm inspection report dated August 21, 2025, listed the following deficiencies. Evidence of corrective action was unavailable at the time of survey.

a. The sounders in the smoke/sounders in rooms 211, 213, 215, 224, 225, 227, 228, 229, 231, 305, 311, 314, 315, 317, 323, 326 & 327 did not function at the time of the annual inspection and need to be replaced;
b. The tampers in the pit did not report to the fire alarm control panel at the time of inspection and need to be repaired or replaced.

Exit interview with the Administrator and Regional Operations Manager on October 6, 2025, at 11:45 a.m. confirmed the listed above deficiencies.

2. Observation on October 6, 2025, at 11:15 a.m., revealed the facility fire alarm panel was in trouble mode at the time of survey.

Exit interview with the Administrator and Regional Operations Manager on October 6, 2025, at 11:45 a.m. confirmed the fire alarm panel was in trouble mode.

Plan of Correction - To be completed: 02/28/2026

a. sounders in the smoke/sounders in rooms 211, 213, 215, 224, 225, 227, 228, 229, 231, 305, 311, 314, 315, 317, 323, 326 & 327 were replaced and fixed. Tilley Fire Company will audit quarterly for any issues and will be brought to QAPI for review.
b. The tampers in the pit were chained and documentation from City Township approved method and will update Life Safety binder.
2. New install of a 7ah power supply and programming for fire panel to update to all troubles off the fire panel. Maintenance Director will audit weekly x3 then monthly x2, Any issues will be fixed and brought to QAPI for review

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353
Based on document review and interview, it was determined the facility failed to maintain automatic sprinkler system components, affecting the entire facility.

Findings include:

1. Document review on October 6, 2025, at 9:45 a.m., revealed the August 21, 2025, sprinkler inspection reports listed the following deficiencies. Evidence of corrective action was unavailable at the time of survey.

a. Sprinkler System 1: Several sprinklers in the building were observed to be too high at the time of the annual inspection and need to be adjusted;
b. Sprinkler System 1: The tampers in the pit did not function at the time of inspection and need to be repaired or replaced. The valves are chained and locked;
c. Sprinkler System 1: The inspectors test piping is not secure in the IT Room on the first floor. The pipe has one strapped secured to a network rack. This shall be corrected ASAP;
d. Sprinkler System 2: The Mansion Building was not accessible for inspection 05/03/23 through 8/21/2025 due to safety concerns and health concerns; and was found condemned. The condition of the sprinkler system is unknown.

Exit interview with the Administrator and Regional Operations Manager on October 6, 2025, at 11:45 a.m. confirmed the listed deficiencies.

Plan of Correction - To be completed: 02/28/2026

a. Sprinkler System 1: All sprinklers' heads were adjusted to proper height. Tilley Fire Company will audit quarterly regarding any issues and will be brought to QAPI for review.
b. Sprinkler System 1: documentation from City Township and Tilley Fire Company approved method and will update Life Safety binder.
c. Sprinkler System 1: test pipe secured properly to ceiling in IT Room. All other sprinklers are secured properly per Tilley Fire Company
D. Sprinkler System 2: Hired outside engineer to complete safety and health concerns. Engineer completed inspection and deemed it safe to operate in. Tilley Fire Company contacted to complete sprinkler inspection and scheduled out to complete, 2/20/2026. Any issues will be fixed then moving forward, Tilley Fire Company will audit quarterly regarding any issues and will be brought to QAPI for review.

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