IT WAS after midnight in mid-April, and Greg Harlen would not stop screaming in his room at the Cardinal Krol Center.
Harlen, 52, a resident of the Philadelphia Archdiocese-run home for mentally handicapped men, was lying in his bed, writhing in pain.
Both of his hips had been shattered.
Later that morning, staffers decided to call 9-1-1. Harlen, who had Down syndrome, was taken to Springfield Hospital - nearly 20 hours after he is believed to have suffered a mysterious trauma that broke his hips.
He died in the hospital about a month later of complications from his injuries.
"I can't imagine the pain he was in," said Harlen's sister, Sheila Phelan. "I don't understand why they didn't send him to the hospital long before they did."
Harlen's death has renewed scrutiny of the center's operations, five years after the state Health Department released a scathing report that said the 131-bed home in Delaware County had failed to protect its residents from sexual abuse by another resident - and other serious violations.
"What's happening out there?" Phelan asked. "Is this normal, that people scream?"
Archdiocese spokeswoman Donna Farrell said she couldn't comment on Harlen's case because the investigation was ongoing.
"Greg's death was a real loss and hit everyone here very hard," she said.
It remains unclear how Harlen was injured, whether he was beaten by another person or fell. He was unable to speak afterward.
Harlen's family believes that he was assaulted by a caregiver there, but police are awaiting the neuropathology results from his autopsy before deciding whether to proceed with a criminal investigation.
Philadelphia's Department of Behavioral Health and Mental Retardation Services determined last month that Harlen, formerly of Northeast Philadelphia, should have been taken to the hospital sooner.
The department found that, "given the intensity and duration" of Harlen's crying on April 16 and 17 and other indications that he was in pain, "more timely action should have been taken by the agency to assess Mr. Harlen for injuries and necessary medical treatment."
Records show that the center, in Marple Township across from Ss. Peter and Paul Cemetery, has repeatedly been cited by the state in recent years for a range of violations, some of which are recurring.
Over the past year alone, the center's state-issued certification of compliance was temporarily revoked twice due to "serious substandard conditions" there.
"Many of them are very serious violations," said Jacqueline Beilharz, of the Disability Rights Network of Pennsylvania, a federally mandated nonprofit that seeks to protect the civil rights of people with disabilities.
Health Department inspectors have found that the center has failed to maintain complete medical records, properly train its staff, protect residents from physical abuse by other residents and conduct full background checks on some employees.
Kathy Perry, of the Arc of Delaware County, an advocacy group for people with disabilities, said her office has received several complaints about the center.