Inspection Reports for
Northland Heights

PA, 15237

Back to Facility Profile

32 Reports

2019–2026

Inspection Report — Mar 13, 2026

Follow-Up
Date: Mar 13, 2026

Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by a complaint and incident to review the submitted plan of correction.

Complaint Details
The visit was complaint-related and involved an incident of resident altercation with physical and verbal abuse. Protective services and law enforcement were involved. The complaint was addressed with safety interventions and monitoring.
Findings
The submitted plan of correction was determined to be fully implemented with continued compliance required. The report details an altercation between residents and subsequent interventions including safety checks and staff training.

Citations (1)
42b Abuse/Neglect: A resident altercation occurred involving physical contact and resulted in red markings on a resident. Interventions including safety checks and staff training were implemented and monitored.
Report Facts
Residents Served: 74 Special Care Unit Residents Served: 16 Hospice Current Residents: 4 Residents Age 60 or Older: 74 Residents Diagnosed with Mental Illness: 4 Residents Diagnosed with Intellectual Disability: 1 Residents with Mobility Need: 36 Residents with Physical Disability: 1

Inspection Report — Nov 24, 2025

Date: Nov 24, 2025

Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident at the facility.

Findings
No regulatory citations or deficiencies were identified during this inspection.

Report Facts
Residents Served: 71 Special Care Unit Residents Served: 15 Hospice Current Residents: 10

Notice — Aug 20, 2025

Date: Aug 20, 2025

Visit Reason
The document serves to notify the facility that a waiver request for direct care staff qualification requirements has been granted under 55 Pa.Code § 2800.19.

Findings
The waiver allows a specified employee to serve as direct care staff based on education obtained outside the United States, equivalent to a U.S. Bachelor Degree, subject to documentation and annual review.

Employees mentioned
NameTitleContext
Theresa HartmanBureau Director, Human Services LicensingSigned the waiver approval letter.

Inspection Report — Jul 7, 2025

Renewal
Date: Jul 7, 2025

Visit Reason
The inspection was conducted as a renewal inspection of the facility's license, with an unannounced full inspection on 07/07/2025 and 07/08/2025.

Findings
The inspection identified several deficiencies including improper storage of poisonous materials, missing emergency procedures posting, failure to meet fire drill evacuation time requirements, and routine scheduling of fire drills during sleeping hours. Plans of correction were accepted and implemented by early August 2025.

Citations (4)
Poisonous materials were not stored in their original labeled containers; a spray bottle with purple liquid was improperly labeled.
Emergency procedures for the assisted living residence and local municipality were not posted in a public and conspicuous place.
Fire drill evacuation time exceeded the safe evacuation time specified by a fire safety expert; repeat violation noted.
Fire drills were routinely held during sleeping hours, which is against regulations; repeat violation noted.
Report Facts
Residents Served: 67 Special Care Unit Residents Served: 13 Hospice Residents: 11 Residents Age 60 or Older: 67 Residents Diagnosed with Mental Illness: 5 Residents Diagnosed with Intellectual Disability: 1 Residents with Mobility Need: 29 Residents with Physical Disability: 1 Fire Drill Evacuation Time: 600 Safe Evacuation Time: 264

Inspection Report — Apr 29, 2025

Complaint Investigation
Date: Apr 29, 2025

Visit Reason
The inspection was conducted as a complaint and incident investigation during an unannounced partial licensing inspection.

Complaint Details
The inspection was complaint-related and no deficiencies were found, indicating no substantiated issues.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.

Report Facts
Residents Served: 63 Special Care Unit Residents Served: 13 Hospice Current Residents: 12 Resident Demographics: 0 Resident Demographics: 5 Resident Demographics: 31 Resident Demographics: 63 Resident Demographics: 1 Resident Demographics: 2 Total Daily Staff: 94 Waking Staff: 71

Notice — Apr 22, 2025

Date: Apr 22, 2025

Visit Reason
The document responds to a request for a waiver of Pennsylvania Code § 2600.190(b) to allow unlicensed direct care staff to administer subcutaneous injections of GLP-1 agonist medications.

Findings
The waiver outlines specific training and monitoring requirements for direct care staff administering GLP-1 agonist injections, including successful completion of Department-approved courses, in-person training, annual training hours, and facility policies for administration and clinical contact availability.

Employees mentioned
NameTitleContext
Theresa HartmanBureau Director, Human Services LicensingSigned the waiver approval letter.

Notice — Dec 2, 2024

Date: Dec 2, 2024

Visit Reason
The document serves to notify the facility that a waiver request to waive the high school diploma/GED or nurse aide registry requirement for a direct care staff person has been granted under specified conditions.

Findings
The waiver is granted based on documentation that the staff member's education from outside the United States is equivalent to a U.S. Bachelor's degree. The Department will review this waiver annually during inspections to ensure compliance with conditions.

Employees mentioned
NameTitleContext
Theresa HartmanBureau Director, Human Services LicensingSigned the waiver approval letter.

Notice — Nov 14, 2024

Date: Nov 14, 2024

Visit Reason
The document serves to notify the facility that a waiver request to waive the high school diploma requirement for a direct care staff person has been granted under Pennsylvania regulations.

Findings
The waiver is granted with conditions including documentation of education and training to be maintained by the facility and subject to annual review during inspections. Noncompliance with conditions may result in waiver termination or licensing action.

Employees mentioned
NameTitleContext
Theresa HartmanBureau Director, Human Services LicensingSigned the waiver approval letter.

Notice — Aug 22, 2024

Date: Aug 22, 2024

Visit Reason
The document serves to grant a waiver for a direct care staff member at Northland Heights who received their high school education outside the United States, allowing them to serve without a traditional high school diploma as per state code.

Findings
The waiver is granted under specific conditions including documentation of education equivalency and record keeping by the facility. The Department will review this waiver annually during inspections to ensure compliance.

Employees mentioned
NameTitleContext
Theresa HartmanBureau Director, Human Services LicensingSigned the waiver approval letter.

Notice — Jul 22, 2024

Date: Jul 22, 2024

Visit Reason
The document serves to notify Northland Heights that their request to waive the requirement for direct care staff to have a high school diploma, GED, or active registry status was granted under specified conditions.

Findings
The waiver is granted with conditions including documentation of education and training to be maintained by the facility and subject to annual review during inspections. Noncompliance may result in waiver termination or other licensing actions.

Employees mentioned
NameTitleContext
Theresa HartmanBureau Director, Human Services LicensingSigned the waiver approval letter.

Notice — Jul 16, 2024

Date: Jul 16, 2024

Visit Reason
The document serves to notify the facility that their request to waive the requirement for direct care staff to have a high school diploma, GED, or active registry status was granted under specified conditions.

Findings
The waiver is granted based on documentation that the staff member's education obtained outside the United States is equivalent to a Bachelor Degree from a regionally accredited U.S. institution. The facility must maintain documentation and comply with conditions to retain the waiver.

Employees mentioned
NameTitleContext
Theresa HartmanBureau Director, Human Services LicensingSigned the waiver approval letter.

Notice — May 17, 2024

Date: May 17, 2024

Visit Reason
The document serves as a waiver approval for Northland Heights LLC regarding the administrator training and orientation requirements under 55 Pa.Code § 2600.64.

Findings
The waiver allows the named individual to serve as administrator while completing required training courses and competency tests by specified dates. The home is expected to be in compliance with all regulations by July 1, 2024.

Inspection Report — Apr 4, 2024

Date: Apr 4, 2024

Visit Reason
The inspection was a partial, unannounced licensing inspection conducted due to provisional and incident reasons.

Findings
No regulatory citations or deficiencies were identified as a result of this inspection.

Report Facts
Residents Served: 38 Special Care Unit Residents Served: 7 Hospice Residents: 3 Resident Support Staff: 0 Total Daily Staff: 63 Waking Staff: 47 Residents Age 60 or Older: 37 Residents Diagnosed with Mental Illness: 2 Residents Diagnosed with Intellectual Disability: 1 Residents with Mobility Need: 25 Residents with Physical Disability: 2

Inspection Report — Feb 21, 2024

Renewal
Date: Feb 21, 2024

Visit Reason
The inspection visit was conducted as a renewal, provisional licensing inspection with multiple inspection dates from February to May 2024 to assess compliance with 55 Pa. Code Chapter 2800 relating to Assisted Living Residence.

Findings
The facility was found to be in compliance overall, but multiple deficiencies were cited including expired boiler certificates, incomplete criminal background checks, staff qualifications, fire safety training, sanitary conditions, elevator certificates, resident equipment safety, medication labeling and administration, resident abuse reporting, and record confidentiality. Plans of correction were accepted and implemented with follow-up inspections scheduled.

Citations (30)
Boiler certificates expired in January 2024.
Criminal background check request for staff person A was still pending review.
Staff persons A and B did not have required high school diploma, GED, or active nurse aide registry status.
Staff person C had not received required fire safety orientation.
Ancillary staff person C did not complete required orientation on resident rights, emergency medical plan, abuse reporting, and core competencies within 40 hours.
Staff persons A and C did not receive dementia-specific training within 30 days of hire.
No grab bars installed in two women's restrooms on 1st floor.
Half bed rails on resident beds were not well-secured, posing entrapment/fall hazards.
No paper towels or other safe hand drying means in women's bathroom across from business office.
Elevator certificate expired for one unit; no certificate for second elevator.
No bedside table or shelf beside resident #3's bed.
Beds of residents #2, #3, and #4 lacked operable bedside lighting.
Food stored on floor in walk-in freezer.
Food stored in unsealed or uncovered containers in kitchen and special care unit.
Outdated and unsealed food found in kitchen freezer.
Fire drill logs incomplete or inaccurate regarding exit routes and resident counts.
Evacuation times during fire drills exceeded maximum safe evacuation time specified by fire safety expert.
Fire drill during sleeping hours not conducted within required 6-month interval.
Fire drills conducted routinely at same time of day and week.
First aid kit in transport van missing thermometer, eye coverings, and tweezers.
Medication bottle for Eliquis missing pharmacy label.
Resident glucometers not calibrated to current date and time.
Half-length bed rails used on both sides of resident #1's bed without meeting regulatory criteria.
Resident #1's assessment did not include diagnoses of history of falls and muscle weakness.
Resident #1's support plan did not document how the home will meet multiple care needs.
No code posted for locking mechanism on stairwell exit door next to unit 212.
Correction fluid used on resident #2's contract with overwritten text.
Resident records left unlocked and unattended in nurses' station.
Resident #1 was verbally and physically abused by staff covering resident's mouth and face, causing abrasion.
Resident #1's prescribed medications were not administered on multiple dates due to unavailability.
Report Facts
Inspection dates: 6 Residents served: 36 Special Care Unit residents served: 7 Staffing hours: 58 Waking staff: 44 Deficiency counts: 30 Residents served: 38 Staffing hours: 60 Waking staff: 45 Residents served: 35 Staffing hours: 49 Waking staff: 37

Employees mentioned
NameTitleContext
Juliet MarsalaDeputy SecretarySigned licensing letter and certificate of compliance

Inspection Report — Nov 21, 2023

Complaint Investigation
Date: Nov 21, 2023

Visit Reason
The inspection was conducted as a complaint investigation and fine review, as indicated by the reason 'Complaint, Fine' and the unannounced partial inspection on 11/21/2023.

Complaint Details
The visit was complaint-related with a fine issued. The inspection was unannounced and partial, conducted on 11/21/2023.
Findings
The inspection identified deficiencies related to sanitary conditions with a pervasive urine odor in a resident room, incomplete labeling of prescription medications, and medication storage procedures including unavailable medication for evening administration. Plans of correction were accepted and implemented by 12/26/2023.

Citations (3)
Strong pervasive odor of urine in room #210 and adjoining bathroom.
Pharmacy label for Resident #1's medication was incomplete and did not include the sliding scale portion.
Medication for Resident #2 was not available in the residence for evening administration, noted as a repeat violation.
Report Facts
Residents Served: 35 Special Care Unit Residents Served: 7 Hospice Current Residents: 3 Residents Age 60 or Older: 36 Residents with Mobility Need: 18

Inspection Report — Aug 15, 2023

Complaint Investigation
Date: Aug 15, 2023

Visit Reason
The inspection was conducted as a complaint investigation with provisional license and fine assessment related to violations found during licensing inspections on July 25, August 9, and August 15, 2023.

Complaint Details
The inspection was complaint-related, provisional license was issued, and fines were proposed for multiple violations. The report includes repeated violations and plans of correction with deadlines.
Findings
Multiple violations of 55 Pa. Code Chapter 2800 related to assisted living residence regulations were found, including mistreatment or abuse of residents, failure to submit and comply with plans of correction, and deficiencies in resident care documentation and medication administration. A provisional license was issued and fines were proposed.

Citations (21)
Resident #1's supervision was inadequate, allowing the resident to leave the home unsupervised and wander outside.
Resident #2's resident-residence contract was not completed until after admission.
Resident #2's resident-residence contract was not signed by the resident.
Resident #2's resident-residence contract did not include a fee schedule listing allowable charges.
Residents #2, 3, 4, 5, and 6 did not have signed statements acknowledging receipt of resident rights and complaint procedures.
Residents #2, 3, 7, and 8 medical evaluations lacked immunization history or indication of tuberculin skin test within 2 years.
Resident #1's previous medical evaluation was undated, making it unclear if annual evaluations were completed.
Resident #2's and others' medical evaluations did not include required immunization or tuberculin skin test information.
Resident #2's albuterol nebulizer medication was discontinued but remained in the medication cart.
Resident #4's phenaseptic liquid medication was discontinued but remained in the medication cart.
Resident #3's insulin orders were clarified late and direction stickers were applied after the fact.
Resident #4's oxycodone medication cards were mislabeled and corrected after discovery.
Resident #7's simvastatin medication administration time was corrected after error was identified.
Resident #3's insulin administration did not follow prescribed sliding scale schedule on certain dates.
Resident #4's mucus relief medication was administered differently than prescribed.
Resident #7's hydromorphone medication was not administered as prescribed on certain dates.
Residents #2, 3, 4, 5, and 6 were not educated on their right to refuse medication.
Residents #1, 3, and 9's cognitive preadmission screenings were incomplete or not done in collaboration with required professionals.
Resident #3's admission record lacked documentation of agreement to admission to special care unit.
Resident #2's medical evaluation was not completed on the Department's standardized form.
Resident #3's and #7's medical evaluations were not completed on the Department's standardized form.
Report Facts
Fine Amount: 200 Fine Amount: 120 Number of Violations: 18

Employees mentioned
NameTitleContext
Juliet MarsalaDeputy Secretary, Office of Long-term LivingSigned letter regarding license revocation and provisional license issuance

Inspection Report — Jul 25, 2023

Complaint Investigation
Date: Jul 25, 2023

Visit Reason
The inspection was conducted as a complaint investigation related to alleged mistreatment or abuse of a resident, failure to submit and comply with an acceptable plan of correction, and other regulatory violations.

Complaint Details
The complaint investigation was substantiated with findings of mistreatment and abuse of resident #1, failure to report and supervise staff involved, and multiple regulatory violations related to resident care and documentation.
Findings
Multiple violations were found including resident abuse, neglect, failure to complete required background checks, incomplete medical evaluations, medication errors, and deficiencies in resident admission and support plans. The facility was issued a second provisional license with fines pending correction of violations.

Citations (20)
2800.15a Resident abuse was reported involving staff verbally abusing and mishandling resident #1, with repeated violations noted. The facility failed to immediately report suspected abuse as required.
2800.15b The facility failed to develop and implement a supervision plan or suspend staff involved in the alleged abuse of resident #1.
2800.42b Resident #1 was neglected and verbally abused by staff, including failure to prevent resident agitation and improper handling during toileting and showering.
2800.51 The facility did not complete a criminal background check for direct care staff person C as required by state law.
2800.65g Direct care staff person C provided unsupervised assisted living services without completing the required 18 hours of training.
2800.142a The facility failed to provide supplemental health services properly, including delayed emergency response and incomplete documentation for resident #2.
2800.231c1 Resident #1's cognitive preadmission screening was not completed within 72 hours prior to admission to the special care unit.
2800.234a Resident #1's support plan was incomplete and not updated to reflect all diagnoses and needs.
2800.234b The support plan did not identify all physical, medical, social, cognitive, and safety needs of resident #1.
2800.25b Resident #2's residence contract was not signed by the resident as required.
2800.25c Resident #2's contract did not include a fee schedule listing allowable resident charges.
2800.41e Resident records for multiple residents lacked signed statements acknowledging receipt of resident rights and complaint procedures.
2800.141a Resident medical evaluations lacked immunization history or indication of tuberculin skin tests within 2 years for several residents.
2800.183d Medications for residents #2 and #4 were discontinued but not removed from medication carts as required.
2800.184a Medication containers were not properly labeled with required pharmacy information for residents #3 and #4.
2800.187a Medication administration records showed errors in timing and documentation for resident #7's simvastatin medication.
2800.187d The facility did not follow prescriber's orders accurately for multiple residents' medications.
2800.191 Residents #2, 3, 4, 5, and 6 were not educated on their right to refuse medication as required.
2800.231d Resident #3's admission record lacked documentation of agreement to admission by resident or family as required.
2800.251c Resident #2, #3, and #7's medical evaluations were not completed on the Department's standardized form as required.
Report Facts
Residents served: 40 Fines calculated: 200 Number of violations with Level II severity: 20

Employees mentioned
NameTitleContext
Staff member CNamed in multiple findings related to abuse, neglect, failure to complete background check, and medication errors
Staff member ANamed in resident abuse and neglect findings
Juliet MarsalaDeputy Secretary, Office of Long-term LivingSigned enforcement and licensing correspondence

Notice — Jul 12, 2023

Date: Jul 12, 2023

Visit Reason
The document serves to notify Northland Heights that their request to waive the requirement for direct care staff to have a high school diploma, GED, or active registry status was granted due to education received outside the United States.

Findings
The waiver is granted with conditions including documentation of education and training to be maintained by the facility and subject to annual review during inspections. Noncompliance with conditions may result in waiver termination or other licensing actions.

Employees mentioned
NameTitleContext
Theresa HartmanBureau Director, Human Services LicensingSigned the waiver approval letter.

Inspection Report — Jun 2, 2023

Complaint Investigation
Date: Jun 2, 2023

Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on June 2, 2023, to review compliance with regulations and address specific complaints.

Complaint Details
The inspection was complaint-driven and substantiated by findings of mistreatment or abuse of residents and failure to comply with correction plans.
Findings
The facility was found to have multiple violations including mistreatment or abuse of residents, failure to submit and comply with an acceptable plan of correction, and specific deficiencies such as inoperable window blinds and medication administration documentation errors. A provisional license was issued due to these violations.

Citations (2)
The blind on the window in resident #1's living unit is inoperable and will not go up.
Resident #1's medication administration record documented Lidocaine Patch applied at 8:00 am, but the patch was actually applied at approximately 11:20 am.
Report Facts
Residents Served: 42 Special Care Unit Residents Served: 2 Hospice Residents: 3 Fine per violation per day: 5 Total Fine per violation per day: 210 Number of violations listed for fines: 18

Inspection Report — May 10, 2023

Complaint Investigation
Date: May 10, 2023

Visit Reason
The inspection was conducted as a complaint and incident investigation with unannounced partial inspections on May 10 and 11, 2023.

Complaint Details
The inspection was complaint-driven, triggered by incidents involving resident mistreatment, medication errors, and failure to comply with reporting requirements. The complaint was substantiated with multiple violations found.
Findings
Multiple violations were found including failure to report incidents timely, inadequate assistance with activities of daily living (ADLs), abuse/neglect by staff, lack of proper staff training on fire safety and abuse reporting, missing or incomplete medical evaluations, improper medication storage and administration, and failure to maintain updated resident assessments and support plans.

Citations (12)
Failure to report an incident involving resident #1 to the Department within 24 hours and medication errors not reported.
Resident #2 was improperly transferred and verbally abused by staff person A, who left the resident unattended on the edge of a wheelchair.
Direct care staff person A did not receive required fire safety orientation training on first day of employment.
Direct care staff person A did not receive required orientation training within 40 hours on resident rights, emergency medical plan, abuse reporting, and safe management techniques.
No medical evaluation completed for resident #2 within required timeframe.
Resident #3's previous annual medical evaluation was overdue.
Medication storage violation: contaminated Furosemide tablet for resident #3.
Expired medication (Acetaminophen) present in the facility for resident #3.
Medication administration record for resident #1 missing diagnosis or purpose for Acetaminophen and Cefuroxime.
Failure to administer prescribed Cefuroxime medication timely to resident #1 and failure to administer Trimethoprim to resident #2 due to unavailability.
Resident #3's most recent assessment was overdue.
Quarterly support plan reviews for residents #1 and #4 were not completed timely.
Report Facts
Staffing: 60 Waking Staff: 45 Special Care Unit Residents Served: 2 Hospice Residents: 2 Fines per Violation: 210

Inspection Report — Apr 4, 2023

Renewal
Date: Apr 4, 2023

Visit Reason
The inspection was conducted as a renewal inspection combined with complaint and incident investigations at Northland Heights assisted living residence.

Findings
The inspection identified multiple violations including failure to timely report incidents, confidentiality breaches, incomplete resident contracts, inadequate staff qualifications and training, medication management issues, fire safety deficiencies, and incomplete resident assessments and support plans. A provisional license was issued with a requirement to correct all violations.

Citations (26)
Failure to post current license inspection summaries and regulations in a conspicuous place.
Incident involving missing medication cards was not reported within 24 hours.
Resident records were unlocked and accessible without proper confidentiality safeguards.
Resident contracts were unsigned or missing required signatures.
Quality management plan did not include review of incident reporting and staff training.
Resident medication records lacked signed statements acknowledging receipt of rights and complaint procedures.
Video recording in resident living areas without proper notification or consent.
Criminal background checks and administrator qualifications were incomplete or missing.
Direct care staff lacked required qualifications and training including first aid, fire safety, and dementia-specific training.
Floors, walls, ceilings, windows, doors, and other surfaces were not properly maintained or clean.
Emergency telephone numbers were not posted by telephones in resident rooms.
Resident rooms lacked bedside tables or shelves.
Refrigerator/freezer lacked thermometer; food items were improperly stored or unsealed.
Insufficient emergency drinking water supply for residents.
Fire extinguishers were not inspected annually and fire drills were not properly documented or conducted as required.
Residents were not evacuated to designated meeting places during fire drills and alternate exit routes were not used.
Resident medical evaluations were incomplete or not current.
Menus were not posted one week in advance.
Expired medications and improperly stored medications were found.
Medication records lacked required information including diagnosis or purpose and discontinued medications were not removed.
Medications were not administered as prescribed and some medications were unavailable for administration.
Staff administering medications had not completed required annual competency training.
Residents were not educated on their right to refuse or question medications.
Resident assessments and support plans were not completed timely or reviewed quarterly as required.
Resident support plans were unsigned or lacked documentation of refusal to sign.
Cognitive preadmission screenings and admission agreement documentation for special care unit residents were incomplete or missing.
Report Facts
Staffing: 62 Waking Staff: 47 Fine per violation per day: 5 Total Fine per violation: 210 Number of violations fined: 18 Emergency water supply: 11 Required emergency water supply: 138 Fire drill maximum evacuation time: 201

Employees mentioned
NameTitleContext
Colleen RoyPresident/COOFacility leadership named in licensing and enforcement correspondence
Lestia FetzerWorkload ManagerDepartment contact for appeals and enforcement
Larry MazzaReviewerReviewer of plan of correction submissions
Theresa HartmanBureau DirectorCopied on licensing correspondence
Sheila PageDirector of OperationsCopied on licensing correspondence
Brent SutherlandRegional DirectorCopied on licensing correspondence
Staff person AAdministratorNamed in violations related to criminal background check and qualifications
Staff person BDirect Care StaffNamed in violations related to qualifications, training, and medication administration
Staff person CDirect Care StaffNamed in violations related to training and medication administration
Staff person DDirect Care StaffNamed in violations related to training, medication administration, and dementia training
Staff person EDirect Care StaffNamed in violations related to training and medication administration; noted as retired
Staff person FDirect Care StaffNamed in violations related to medication administration training
Staff person GDirect Care StaffNamed in violations related to medication administration training
Staff person HDirector of NursingNamed in medication discontinuation violation

Inspection Report — Apr 4, 2023

Complaint Investigation
Date: Apr 4, 2023

Visit Reason
The inspection was conducted due to a combination of renewal, complaint, and incident reasons, including multiple licensing inspections and complaint investigations.

Complaint Details
The complaint investigation revealed incidents of medication errors not reported timely, resident abuse and neglect by staff, failure to provide assistance with activities of daily living as per resident plans, and inadequate staff training and qualifications. Multiple repeat violations were noted.
Findings
The facility was found to have multiple violations including failure to timely report incidents, medication administration errors, inadequate staff training and qualifications, deficiencies in resident care and abuse, incomplete medical evaluations and assessments, fire safety violations, and issues with medication storage and documentation. Numerous repeat violations were noted.

Citations (50)
2800.3d The assisted living residence did not post current license inspection summaries and regulations in a conspicuous place.
2800.16c Incident reporting was delayed for missing medication cards and medication errors were not reported timely to the Department.
2800.17 Resident records were left unlocked and accessible, violating confidentiality requirements.
2800.25b Resident contracts were not signed by residents as required.
2800.26b Quality management plan did not include review of incident reporting procedures and staff training.
2800.41e Resident contracts lacked signed statements acknowledging receipt of resident rights and complaint procedures.
2800.42s Video recording occurred in numerous common areas including hallways and resident doorways without proper resident notification or consent.
2800.51 Criminal background checks were not completed for the administrator upon transfer to Pennsylvania.
2800.53a The administrator did not have documented qualifications as required by regulation.
2800.54a Direct care staff lacked required qualifications such as high school diploma or nurse aide registry status.
2800.63a Insufficient staff trained in first aid and CPR were present during night shifts.
2800.64a The administrator had not completed the required orientation program prior to employment.
2800.65a Direct care staff person B did not receive required fire safety and emergency preparedness training on first work day.
2800.65g Direct care staff persons B and C did not complete required 18 hours of initial direct care training and worked unsupervised.
2800.65h Direct care staff person D received only 10 hours of required 16 hours annual training during 2022.
2800.65i Direct care staff persons D and E did not receive required training on medication self-administration, resident needs, infection control, and care for residents with mental illness during 2022.
2800.65j Direct care staff persons D and E did not receive required annual training on fire safety and emergency preparedness during 2022.
2800.69 Direct care staff persons D and E did not receive required dementia-specific training during 2022.
2800.88a The lock on the door leading to the 2nd floor special care unit courtyard/patio was inoperable.
2800.91 Emergency telephone numbers were not posted on or by the telephone in living unit #508.
2800.101j Resident #6’s living unit lacked a bedside table or shelf.
2800.103f No thermometer was present in the freezer of the 2nd floor special care unit refrigerator/freezer.
2800.103g Numerous food items in the kitchen breakfast freezer were opened and unsealed.
2800.107c The residence did not maintain a 3-day supply of emergency drinking water for residents.
2800.131f Fire extinguishers had not been inspected and approved by a fire safety expert since March 2022.
2800.132c The residence had not documented monthly fire drills since 9/31/22.
2800.132d The residence exceeded the maximum evacuation time specified by a fire safety expert during multiple fire drills.
2800.132e No fire drill was held during sleeping hours since 6/29/21.
2800.132f The residence used the same exit routes during four consecutive fire drills.
2800.132h Not all residents were evacuated to a designated meeting place during multiple fire drills.
2800.141a Resident #1's and #6's medical evaluations were incomplete, missing immunization history, tuberculin skin test results, or mobility assessment.
2800.141b Resident #5’s most recent medical evaluation was not completed annually.
2800.162c The weekly menu was not posted in a conspicuous and public place in the residence.
2800.183d Resident #8 had expired medication (Milk of Magnesia) in the medication cart.
2800.183e Resident #5 and #8 had medications open and undated, not labeled with discard dates per manufacturer instructions.
2800.184a Resident #5’s medication cards lacked prescribed dosage on one pharmacy label.
2800.185a Resident #5’s glucometer was not set to the current date and resident #8’s blood sugar documentation was inconsistent.
2800.186a Resident #5 was prescribed a discontinued medication without a prescriber’s discontinuation order present.
2800.187a Resident #1’s and #7’s medication administration records lacked diagnosis or purpose for multiple medications.
2800.187d Resident #1, #5, and #7 were not administered prescribed medications as ordered, including delays and missing doses.
2800.190a Several direct care staff had not completed required annual practicums for medication administration course.
2800.191 Residents #1 and #4 were not educated on their right to refuse or question medication if they believe there may be an error.
2800.224a Resident #7’s initial assessment was not signed by the assessor within 30 days prior to admission.
2800.225a Resident #5’s most recent assessment was not completed annually.
2800.227c Resident #1’s and #4’s quarterly support plan reviews were not completed timely.
2800.227h Resident #1’s support plan was not signed and did not document refusal or inability to sign.
2800.231c1 Resident #1’s cognitive preadmission screening was undated and not confirmed to be completed within 72 hours prior to admission to the special care unit.
2800.231d Resident #1’s record lacked documentation of agreement to admission to the special care unit.
2800.101q The blind on the window in resident #1's living unit was inoperable.
2800.187b Medication administration times were not recorded at the time medication was administered for resident #1.
Report Facts
Residents served: 46 Residents served: 44 Residents served: 42 Staff persons: 62 Staff persons: 60 Staff persons: 59 Fines calculated: 210 Residents requiring emergency water: 46 Emergency drinking water available: 11

Employees mentioned
NameTitleContext
Staff person AAgency staff personNamed in findings related to resident abuse, neglect, and failure to provide ADL assistance
Staff person BDirect care staff personNamed in findings related to lack of qualifications and training
Staff person CDirect care staff personNamed in findings related to lack of qualifications and training
Staff person DDirect care staff personNamed in findings related to medication administration and training deficiencies
Staff person EDirect care staff personNamed in findings related to medication administration and training deficiencies
Staff person FDirect care staff personNamed in findings related to medication administration and training deficiencies
Staff person GDirect care staff personNamed in findings related to medication administration and training deficiencies
Staff person HDirector of NursingNamed in findings related to medication discontinuation and record keeping

Inspection Report — Jan 6, 2023

Follow-Up
Date: Jan 6, 2023

Visit Reason
The inspection was conducted as a follow-up review of the submitted plan of correction for the facility following an incident.

Findings
The submitted plan of correction was determined to be fully implemented. The report details multiple prior violations related to resident assessments, medical evaluations, cognitive screenings, no objection statements, and support plans, all of which have corrective actions and audits planned or completed.

Citations (5)
Incomplete initial assessment for resident #1, missing details on eating assistance and special dietary needs.
Medical evaluation for resident #1 did not indicate need for dementia-related care in a secured area.
Resident #1 did not have a written cognitive preadmission screening completed within 72 hours prior to admission to the special care unit.
Resident #1's record lacked documentation of agreement by resident or family for admission to the special care unit.
Resident #1's support plan was not developed, implemented, and documented within 72 hours of admission to the special care unit.
Report Facts
Residents Served: 36 Special Care Unit Residents Served: 3 Waking Staff: 38 Total Daily Staff: 51 Residents Age 60 or Older: 36 Residents with Mobility Need: 15

Inspection Report — Nov 1, 2022

Complaint Investigation
Date: Nov 1, 2022

Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial review of the facility on 11/01/2022 and 11/01/2022 off-site review, to determine compliance with regulations and verify the submitted plan of correction.

Complaint Details
The inspection was triggered by a complaint, as indicated by the inspection reason. The submitted plan of correction was reviewed and determined to be fully implemented.
Findings
The inspection found multiple deficiencies related to incident reporting, medication management, and following prescriber's orders, including failure to report a resident death within 24 hours, presence of discontinued medications on medication carts, and missed or undocumented medication administrations. Plans of correction were accepted and implemented by 12/14/2022.

Citations (4)
Failure to report the death of Resident #1 to the Department’s assisted living residence office or complaint hotline within 24 hours.
Discontinued medications for Resident #1 and Resident #2 were found on the residence’s medication cart.
Medication administration records were not properly documented; medications were found not administered and left in a medicine cup, and refusals were not documented.
Failure to follow prescriber's orders including missed medication administrations, unavailable medications in the home, and missed blood glucose monitoring and insulin administration for Resident #4.
Report Facts
Residents Served: 32 Special Care Unit Residents Served: 0 Current Hospice Residents: 1 Residents Age 60 or Older: 31 Residents Diagnosed with Mental Illness: 1 Residents Diagnosed with Intellectual Disability: 1 Residents with Mobility Need: 12 Residents Receiving Supplemental Security Income: 0 Residents with Physical Disability: 0 Total Daily Staff: 44 Waking Staff: 33

Employees mentioned
NameTitleContext
Director of Personal CareDirector of Personal CareNamed in relation to incident reporting and medication management deficiencies and responsible for education and audits
AdministratorAdministratorNamed in relation to incident reporting and medication management deficiencies and responsible for education and confirmation of incident report submissions

Inspection Report — Aug 11, 2022

Follow-Up
Date: Aug 11, 2022

Visit Reason
The inspection visit on 08/11/2022 was conducted as a follow-up to review the submitted plan of correction related to an incident involving alleged resident abuse and supervision violations.

Complaint Details
The visit was complaint-related due to an allegation of abuse involving resident #1 and direct care staff person A. The allegation was substantiated with findings of failure to report abuse timely and failure to properly supervise the staff involved.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing allegations of resident abuse and failure to properly supervise staff. The report notes repeated violations related to abuse reporting and supervision, with corrective actions including internal investigations, reprimands, and suspension plans.

Citations (2)
Failure to immediately report suspected abuse of a resident and comply with reporting requirements.
Failure to immediately develop and implement a plan of supervision or suspend the staff person involved in the alleged abuse incident.
Report Facts
Residents Served: 23 Total Daily Staff: 29 Waking Staff: 22 Residents Age 60 or Older: 23 Residents with Mobility Need: 6

Inspection Report — Jun 23, 2021

Complaint Investigation
Date: Jun 23, 2021

Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 06/23/2021.

Complaint Details
The inspection was complaint-driven as stated under Inspection Type: Partial and Reason: Complaint.
Findings
The inspection found multiple violations including unlocked and unattended resident records accessible in various nursing stations, improper labeling and storage of poisonous materials, uncovered trash cans in the kitchen, and improperly stored food items. Plans of correction were accepted and implemented with staff education and physical security improvements.

Citations (4)
Resident records were unlocked, unattended, and accessible in multiple areas including nurses' stations and unlocked cabinets.
Poisonous materials were not stored in original, labeled containers; a spray bottle labeled 'Enzyme Cleaner' was not properly labeled.
Trash can in the kitchen was missing the flip section of the lid, not preventing penetration of insects and rodents.
Food was stored improperly; an open unsealed loaf of bread was found in a metal bin with other bread products.
Report Facts
Residents Served: 14 Special Care Unit Residents Served: 4 Hospice Residents: 1 Residents with Mobility Need: 7 Residents 60 Years or Older: 14 Residents Diagnosed with Intellectual Disability: 1

Employees mentioned
NameTitleContext
Director of Personal CareResponsible for auditing nursing stations and educating staff on confidentiality of records.
AdministratorResponsible for auditing nursing stations and educating staff on confidentiality of records.
Maintenance DirectorResponsible for auditing chemical storage and educating staff on proper labeling of poisons.
Culinary Services DirectorResponsible for auditing kitchen trash cans and food storage, and educating staff on related regulations.
ChefResponsible for auditing kitchen food storage and educating staff on proper food storage.

Inspection Report — Apr 30, 2021

Complaint Investigation
Date: Apr 30, 2021

Visit Reason
The inspection was conducted as a complaint investigation during an unannounced visit on 04/30/2021.

Complaint Details
The inspection was complaint-related, but no deficiencies or regulatory citations were found, indicating no substantiated issues.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.

Report Facts
Residents Served: 14 Memory Care Residents Served: 3 Hospice Current Residents: 1 Residents Age 60 or Older: 13 Residents Diagnosed with Mental Illness: 2 Residents with Mobility Need: 4

Inspection Report — Mar 3, 2021

Complaint Investigation
Date: Mar 3, 2021

Visit Reason
The inspection was conducted as a complaint investigation following allegations of resident abuse and other regulatory concerns at the facility.

Complaint Details
The complaint investigation was substantiated with findings of resident abuse, failure to report abuse timely, and multiple regulatory violations related to resident care and documentation.
Findings
The investigation found multiple violations including resident abuse by staff, failure to immediately report abuse, lack of dignity and respect towards residents, incomplete medical evaluations, improper use of bedside rails, incomplete resident support plans, and deficiencies in preadmission screening documentation.

Citations (9)
Failure to immediately report suspected abuse of residents and staff yelling at residents, causing distress.
Staff did not treat residents with dignity and respect, including yelling and name-calling.
Medical evaluations missing timely tuberculin skin test documentation for residents.
Bedside rails used without physician order or inclusion in resident support plan.
Resident support plans incomplete or missing documentation of copies given to residents.
Resident assessments missing key information such as assistance needs and fall risk.
Final support plans not revised timely to reflect resident needs and changes.
Cognitive preadmission screening incomplete and undated.
Non-dementia resident admitted to memory care unit without proper medical evaluation within required timeframe.
Report Facts
Inspection dates: 4 Residents served: 104 Staff total daily: 109 Waking staff: 82 Residents age 60 or older: 11 Residents with mental illness: 6 Residents with mobility need: 5 Current hospice residents: 1

Inspection Report — Oct 5, 2020

Renewal
Date: Oct 5, 2020

Visit Reason
The inspection was a full, unannounced renewal inspection conducted on 10/05/2020 to assess compliance with licensing requirements.

Findings
The inspection identified multiple deficiencies including unlocked confidential resident records, unsigned resident contract, inadequate trash removal frequency, incomplete first aid kit supplies, improper storage of water, missing emergency procedure postings, medication labeling and documentation errors, missing activity calendar, incomplete medical evaluations, and missing signage for key-locking devices. Plans of correction were implemented or directed for all findings.

Citations (13)
Regulation 2800.17: Resident records were found unlocked and unattended on a bookshelf next to the 6th floor nurse's desk.
Regulation 2800.25b: Resident #1’s resident-residence contract dated 5/10/20 was not signed by the resident at the time of inspection.
Regulation 2800.85c: Trash was removed from the premises every other Friday instead of weekly as required.
Regulation 2800.96a: The first aid kit on the 1st floor lacked gauze pads and nonporous disposable gloves.
Regulation 2800.103d: Twenty gallons of water were stored on the floor in the kitchen storage room.
Regulation 2800.123b: Emergency procedures were not posted in a conspicuous and public place in the residence.
Regulation 2800.184a: Medication labels for residents #1 and #5 did not match the prescribed dosages and instructions.
Regulation 2800.185a: Resident #5’s blood sugar readings were not documented on the medication administration record on multiple occasions.
Regulation 2800.187b: Medication administration records for residents #1, #4, and #5 lacked staff initials for multiple medication administrations.
Regulation 2800.187d: Resident #5’s blood sugar readings documented on the MAR did not correspond with glucometer readings, indicating failure to follow prescriber’s orders.
Regulation 2800.221c: The residence did not have a current weekly activity calendar posted in a public and conspicuous place.
Regulation 2800.231b: Resident #1’s medical evaluation was completed more than 60 days prior to admission to the special care unit and lacked dementia diagnosis and need for special care.
Regulation 2800.233c: Directions for operating key-locking devices were not conspicuously posted near emergency exits in the special care unit.
Report Facts
Residents Served: 5 Special Care Unit Residents Served: 1 Staff Count: 7 Waking Staff: 5

Inspection Report — Aug 27, 2020

Complaint Investigation
Date: Aug 27, 2020

Visit Reason
The inspection was conducted as a complaint investigation following allegations of resident abuse and related incidents at the facility.

Complaint Details
The visit was complaint-related due to allegations of resident abuse involving staff. The abuse allegation was substantiated by the findings of delayed reporting and inadequate staff supervision.
Findings
The inspection found multiple violations including failure to timely report suspected resident abuse, inadequate supervision of staff involved in abuse allegations, unsanitary conditions in a resident's room, incomplete resident assessments, and deficiencies in support plan documentation and participation.

Citations (10)
2800.15a The residence failed to immediately report suspected abuse of resident #1, delaying notification to the local Area Agency on Aging until four days after the incident.
2800.15b The residence did not immediately suspend or implement a supervision plan for staff person B after the abuse allegation; the staff continued unsupervised care for several days.
2800.16c The residence failed to report the incident to the Department’s assisted living complaint hotline within 24 hours as required.
2800.85a Unsanitary conditions were found in resident #1’s bedroom, including breadcrumbs on the floor and a dried reddish substance appearing to be blood.
2800.224a5 Resident #1’s initial assessment lacked documentation of exit seeking behaviors, need for wander guard, and social/recreational needs.
2800.224c6 Resident #1’s preliminary support plan incorrectly documented ability to operate key-locking devices; resident was unable to operate keypad to exit floor.
2800.224c7 Resident #1’s preliminary support plan was not signed by the resident and did not indicate if the resident refused or was unable to participate.
2800.224c10 The residence did not document if a copy of resident #1’s preliminary support plan was requested or provided.
2800.225a2 Resident #1’s assessment was not updated to include significant behavioral changes after admission.
2800.227a The final support plan for resident #1 lacked a completion date, preventing determination if it was completed within 30 days of admission.
Report Facts
Residents Served: 4 Special Care Unit Residents Served: 1

Inspection Report — Dec 12, 2019

Original Licensing
Date: Dec 12, 2019

Visit Reason
The inspection was conducted as a new facility licensing inspection for Northland Heights, which was not yet serving four or more residents at the time of the visit.

Findings
The facility was found to be in substantial compliance with applicable regulations but had several citations related to posting of license and regulations, fire safety approval, health and safety laws, privacy signage, trash receptacles, lighting egress, first aid kit accessibility, food refrigeration, exit door locking devices, fire extinguisher inspection, fire safety inspection, and key-locking devices. Plans of correction were submitted and approved for all violations.

Citations (14)
2800 3.d: The assisted living residence did not post the current license, inspection summary, and chapter 2800 regulations in a conspicuous public place.
2800 14.a: The residence had only a temporary certificate of occupancy and lacked a permanent certificate at the time of inspection.
2800 18: The facility did not post the required Influenza Awareness poster or no smoking signs as required by law.
2800 42s: The home recorded video in public areas but did not post signs indicating video surveillance.
2800 85d: Trash cans in kitchens and bathrooms were not kept covered; a 3/4 full uncovered cardboard box of trash was found in a women's bathroom.
2800 87: Several exit doors in the special care unit were locked or set to night mode with delayed egress without proper signage or override codes.
2800 96c: The first aid kit was not easily accessible; the defibrillator device was empty and located in a locked office when staff was absent.
2800 103f: No thermometer was present in the freezer compartment of the first floor activity room freezer.
2800 121a: Exit doors in the special care unit were equipped with locking devices requiring keypads but lacked posted instructions and had physical obstructions blocking egress routes.
2800 121b: Exit doors in the special care unit were locked with a panic bar and wander guard system without written approval or variance from authorities.
2800 124: The residence failed to notify the local fire department in writing of the address, location of living units, bedrooms, and evacuation assistance needs.
2800 131f: The fire extinguisher in the basement near elevators had not been inspected by a fire safety expert since June 2018.
2800 132b: The residence did not have a fire safety inspection conducted by a fire safety expert.
2800 233c: Directions for operating key-locking devices were not conspicuously posted near exits in the special care unit.
Report Facts
Residents Served: 0

Employees mentioned
NameTitleContext
Cheryl FesterAdministratorNamed in multiple findings and plan of correction approvals

Inspection Report — February 26, 2021

Renewal
Date: February 26, 2021

Visit Reason
The document is a renewal license issued in response to the facility's renewal application to operate an Assisted Living Home, with a reminder that an annual onsite inspection will be conducted within the next twelve months.

Findings
The Department has approved the renewal application and issued a regular license. The Department will conduct an onsite inspection within the next twelve months and take enforcement action if noncompliance is found.

Report Facts

Employees mentioned
NameTitleContext
Jamie L. BuchenauerDeputy SecretarySigned the renewal license letter

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