Inspection Reports for
Oak Leaf Manor North
2901 HARRISBURG PIKE,, LANDISVILLE, PA, 17538
Back to Facility Profile25 Reports
Inspection Report — Apr 24, 2026
Complaint Investigation
Date: Apr 24, 2026
Visit Reason
The inspection was conducted as a complaint investigation following an incident involving resident abuse and contract signature issues at Oak Leaf Manor North.
Complaint Details
The complaint involved a resident in the secured dementia care unit who was physically abused by a staff member who pushed, dragged, and confined the resident, leading to hospital transport and law enforcement arrest. The staff member was charged with abuse of a care dependent person, false imprisonment, and harassment.
Findings
The inspection found violations related to an unsigned resident-home contract due to dementia diagnosis and a serious abuse incident involving a staff member physically abusing a resident in the secured dementia care unit. The staff member was terminated and law enforcement was involved.
Citations (3)
25b Contract Signatures: The resident-home contract was not signed by the resident due to dementia, but was signed by Power of Attorney and Home Designee. Training and audits were planned to ensure proper documentation.
42b Abuse: A staff member physically abused a resident by pushing, dragging, and confining the resident in a room, resulting in injury and hospital transport. The staff member was terminated and arrested.
202 Prohibitions: Staff member forcibly confined a resident in a room by holding the door closed, preventing the resident from leaving, which is prohibited seclusion.
Report Facts
Residents Served: 114
Secured Dementia Care Unit Residents Served: 35
Current Hospice Residents: 6
Residents Age 60 or Older: 110
Residents with Mobility Need: 38
Residents with Physical Disability: 1
Inspection Report — Oct 15, 2025
Complaint Investigation
Date: Oct 15, 2025
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received by the Pennsylvania Department of Human Services.
Complaint Details
The inspection was complaint-driven as indicated by the reason 'Complaint' and the visit date of 10/15/2025. The report documents multiple violations found during this complaint investigation.
Findings
Multiple deficiencies were identified including failure to report a serious incident, unsecured poisonous materials accessible to residents, obstructed egress routes, incomplete medical evaluations, improper medication administration documentation, and incomplete resident assessments. Plans of correction were accepted and implemented by December 4, 2025.
Citations (9)
16c Written Incident Report: The home failed to report an incident involving maggots found on a resident's scalp to the Department within 24 hours as required.
82c Locking Poisonous Materials: Poisonous cleaning products were found unlocked and accessible to residents in the secured dementia care unit.
121a Unobstructed Egress: A walker and window screens blocked the rear stairwell exit egress route in the secured dementia care unit.
141a Medical Evaluation Information: A resident's medical evaluation did not include the resident's medical diagnosis or treatment pertinent to that diagnosis.
185a Implement Storage Procedures: The home lacked procedures to ensure treatments provided by outside agencies were properly documented in resident records.
187b Date/Time of Medication Admin.: Medication administration records lacked staff initials documenting medication administration at the time given.
190a Completion Medication Course: A staff member did not complete required medication administration training and continued to administer medications.
225c Additional Assessment: Resident assessments were not updated to reflect significant changes in condition including attempts to leave the building and use of bedside mobility devices.
251b Record Entries Legible: Correction fluid was used on resident physician communication sheets, violating requirements for permanent, legible, dated, and signed entries.
Report Facts
Residents Served: 109
Secured Dementia Care Unit Residents Served: 37
Hospice Current Residents: 9
Residents Age 60 or Older: 107
Residents with Mobility Need: 40
Residents with Physical Disability: 1
Total Daily Staff: 149
Waking Staff: 112
Inspection Report — Mar 6, 2025
Follow-Up
Date: Mar 6, 2025
Visit Reason
The inspection was conducted as a follow-up review of the facility's plan of correction related to prior deficiencies, specifically regarding incidents of resident abuse and support plan revisions.
Findings
The facility was found to have previously failed to report multiple incidents of resident abuse to the local area agency on aging and the Department, and had not updated resident support plans to reflect behavioral changes. The submitted plan of correction was determined to be fully implemented as of the follow-up inspection date.
Citations (4)
Failure to immediately report suspected abuse of residents to the local area agency on aging.
Failure to report incidents of abuse to the Department within 24 hours as required.
Resident abuse incidents including physical altercations resulting in injuries such as hair loss, bruising, and red marks.
Failure to revise resident support plans to reflect significant behavioral changes resulting in multiple physical altercations.
Report Facts
Residents Served: 112
Staffing Hours: 151
Waking Staff: 113
Secured Dementia Care Unit Residents Served: 33
Hospice Current Residents: 11
Residents Age 60 or Older: 110
Residents with Mobility Need: 39
Residents with Physical Disability: 2
Inspection Report — Sep 4, 2024
Follow-Up
Date: Sep 4, 2024
Visit Reason
The inspection was conducted as a follow-up review to verify the full implementation of the submitted plan of correction related to prior deficiencies at Oak Leaf Manor North.
Findings
The submitted plan of correction was found to be fully implemented, with continued compliance required. Several deficiencies related to resident abuse reporting, medication administration training, medical evaluations, and admission support plans were addressed with corrective actions and training completed.
Citations (6)
Failure to immediately report suspected resident abuse to the Local Area Agency on Aging.
Failure to report incidents of abuse to the Department within 24 hours as required.
Resident abuse incidents including physical altercations and improper handling by staff.
Staff member administered medications without completing Department-approved medication administration training.
Resident medical evaluations did not include diagnosis of dementia or need for secured dementia care unit placement.
Initial support plans for residents admitted to the secured dementia care unit were not completed within required timelines.
Report Facts
Residents Served: 97
Secured Dementia Care Unit Residents Served: 30
Current Hospice Residents: 6
Residents Age 60 or Older: 96
Residents with Mobility Need: 31
Residents with Physical Disability: 1
Total Daily Staff: 128
Waking Staff: 96
Inspection Report — May 15, 2024
Renewal
Date: May 15, 2024
Visit Reason
The inspection was conducted as a full, unannounced review for renewal, complaint, and incident reasons from 05/15/2024 to 05/17/2024.
Findings
The inspection identified multiple deficiencies including failure to post required smoking signage, outdated resident contracts, abuse by a staff member, lint accumulation in dryers, missing rabies vaccination certificates for facility cats, incomplete first aid kits, medication storage and documentation issues, incomplete medical evaluations for secured dementia care unit residents, missing no objection statements, incomplete resident-home contracts, and incorrect emergency exit passcode signage. Plans of correction were accepted and implemented for all deficiencies.
Citations (14)
Failure to post 'Smoking Permitted in Designated Areas Only' or 'No Smoking' signs at facility entrances.
Resident contracts pre-dating legal entity change in 2023 were not updated.
Staff Member A verbally and physically abused multiple residents, including belittling, humiliating, and physically grabbing a resident.
Lint trap in Dryer 1 of the 1st floor secure dementia care unit had thick lint accumulation.
Missing current certificates of rabies vaccinations for two cats living in the facility.
First aid kit in the bus used for resident transport lacked thermometer, tweezers, and eye coverings.
Loose pills found in medication drawers of two medication carts.
Glucometer calibration issues and missing documentation of blood sugar readings; PRN medications not available for some residents.
Staff Person B administered medications without completing Department-approved medication administration course.
Resident support plan did not include hospice status for a resident admitted on hospice.
Medical evaluations for residents in the Secure Dementia Care Unit did not state the need for secured care.
No documentation that resident and designated person did not object to admission to the secured dementia care unit.
Resident-home contracts lacked disclosure of services, admission and discharge criteria, change in condition policies, special programming, and costs and fees for the Secure Dementia Care Unit.
Incorrect passcode posted at emergency exit in the Secure Dementia Care Unit courtyard.
Report Facts
Residents Served: 96
Residents Served in Secured Dementia Care Unit: 26
Current Hospice Residents: 6
Total Daily Staff: 125
Waking Staff: 94
Residents with Mobility Need: 29
Residents with Physical Disability: 1
Inspection Report — Sep 25, 2023
Follow-Up
Date: Sep 25, 2023
Visit Reason
The inspection was conducted as a follow-up review of the facility's plan of correction related to incidents of resident abuse and other compliance issues, following an incident-based partial unannounced inspection.
Findings
The facility was found to have incidents of resident-to-resident abuse that were not properly reported initially, deficiencies in resident assessments and support plans, and improper use of restraints. The submitted plan of correction was fully implemented by the dates indicated, including staff training and audits to ensure compliance.
Citations (5)
Failure to immediately report suspected resident abuse as required by the Older Adult Protective Services Act.
Resident abuse incidents including physical aggression among residents were documented.
Improper use of manual restraint on a resident to reduce ability to move arms.
Failure to complete new assessments when resident conditions significantly changed.
Resident support plans did not properly document mental health or behavioral care needs.
Report Facts
Residents Served: 99
Staffing Hours: 131
Waking Staff: 98
Residents Served in Secured Dementia Care Unit: 28
Current Hospice Residents: 4
Residents 60 Years or Older: 98
Residents with Mobility Need: 32
Residents with Physical Disability: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lori Dierolf | Open Door Training and Development Instructor | Provided training on dementia communication and responding to behaviors of dementia; holds multiple certifications. |
Inspection Report — Jul 18, 2023
Original Licensing
Date: Jul 18, 2023
Visit Reason
The inspection was conducted as a licensing inspection for the newly licensed personal care home facility, Oak Leaf Manor North, triggered by a complaint and change in legal entity.
Complaint Details
The inspection was complaint-related and also involved a change in legal entity. Substantiation status is not explicitly stated.
Findings
The facility was found to be in substantial compliance with regulations but had several deficiencies including uncovered enabler bars posing injury risks, insufficient emergency drinking water supply, outdated emergency management agency submission, and missing signatures on support plans. Plans of correction were accepted and implemented.
Citations (4)
Uncovered enabler bars with openings greater than 4 3/4 inches in resident rooms A15 and A16, posing potential injury risk.
The home did not maintain at least a 3-day supply of emergency drinking water; had only 227 gallons available for 104 residents requiring 312 gallons.
Written emergency procedures had not been reviewed and submitted annually to the local Emergency Management Agency since 2021.
Support plan for Resident 1 was missing the assessor's signature.
Report Facts
Residents Served: 104
Residents in Secure Dementia Care Unit: 34
Emergency Drinking Water Required: 312
Emergency Drinking Water Available: 227
Additional Water Obtained: 85
Additional Water Obtained: 50
Total Water Supply After Correction: 360
Staffing Hours - Total Daily Staff: 142
Staffing Hours - Waking Staff: 107
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed licensing letter and certificate. |
Inspection Report — Jul 18, 2023
Follow-Up
Date: Jul 18, 2023
Visit Reason
The inspection was conducted as a follow-up review of the facility's plan of correction and due to a complaint and change of legal entity.
Complaint Details
The inspection was partially triggered by a complaint and change of legal entity. The submitted plan of correction was determined to be fully implemented.
Findings
The facility was found to have implemented the submitted plan of correction fully. Deficiencies related to uncovered enabler bars, insufficient emergency drinking water supply, outdated emergency procedures submission, and missing support plan signatures were addressed and corrected by the facility.
Citations (4)
Uncovered enabler bars with openings greater than 4 3/4 inches in resident rooms A15 and A16, posing potential injury risk.
Insufficient emergency drinking water supply; only 227 gallons available for 104 residents requiring 312 gallons.
Written emergency procedures had not been reviewed and submitted annually to the local emergency management agency since 2021.
Assessor did not sign the support plan developed with Resident 1.
Report Facts
Residents served: 104
Emergency drinking water required: 312
Emergency drinking water available: 227
Additional water obtained: 85
Additional water obtained: 50
Water containers: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dementia Program Director | Signed missing support plan signature page and created quarterly audit for support plan signatures. | |
| Administrator | Completed initial audit of enabler bars, mailed emergency procedures to local emergency management agency, and oversaw corrective actions. | |
| Maintenance Assistant | Obtained additional emergency drinking water to meet compliance. |
Inspection Report — May 31, 2023
Follow-Up
Date: May 31, 2023
Visit Reason
The inspection was an unannounced partial review conducted due to an incident reported at the facility on 05/31/2023.
Findings
The report found a repeat abuse violation where a staff member forcibly held a resident's door closed, preventing the resident from leaving the room. Additionally, a smoking area violation was identified where smoking occurred in an unauthorized courtyard area with fire safety hazards.
Citations (2)
Staff member forcibly held Resident #1's door closed preventing the resident from leaving the room, constituting abuse.
Smoking occurred in an unauthorized courtyard area with fire hazards including non-fire-resistant furniture and cigarette butts near a patio umbrella.
Report Facts
Residents Served: 95
Smoking receptacles found: 1
Cigarette butts found: 12
Inspection Report — Feb 8, 2022
Routine
Date: Feb 8, 2022
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Notice — May 21, 2021
Date: May 21, 2021
Visit Reason
The document is a renewal notification and license issuance letter for Oak Leaf Manor North, a Personal Care Home, confirming receipt of the renewal application 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 confirmation and notification of upcoming annual inspection requirements.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter |
Inspection Report — Mar 24, 2021
Renewal
Date: Mar 24, 2021
Visit Reason
The inspection was conducted for renewal and complaint reasons, including a full unannounced inspection with follow-up reviews.
Findings
The report found deficiencies related to compliance with laws including missing carbon monoxide alarms, unsigned resident contracts, incomplete past menus, and expired vehicle documents. Plans of correction were submitted and accepted with ongoing monitoring.
Citations (4)
No carbon monoxide alarm was found near the gas fireplace in the lobby.
Resident-home contract for a resident was not signed by the payer.
The home keeps past menus for less than 1 month; the oldest menu on record is dated March 14-20.
The inspection for the Ford wheelchair bus expired May 2020.
Report Facts
Residents Served: 91
Secured Dementia Care Unit Residents Served: 33
Hospice Current Residents: 4
Residents Age 60 or Older: 91
Residents with Mobility Need: 40
Inspection Report — Dec 14, 2020
Renewal
Date: Dec 14, 2020
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report — Sep 14, 2020
Routine
Date: Sep 14, 2020
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Notice — Feb 21, 2020
Date: Feb 21, 2020
Visit Reason
The document is a renewal notification and license issuance letter for Oak Leaf Manor North Personal Care Home, confirming receipt of the renewal application and advising of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document; it serves as a license renewal confirmation and certificate issuance.
Report Facts
Notice — Oct 9, 2019
Date: Oct 9, 2019
Visit Reason
The document is a letter granting approval for a revised license capacity increase for the Secured Dementia Care Unit at Oak Leaf Manor North.
Findings
The Department approved an increase in the Secured Dementia Care Unit capacity from 39 to 40 residents. The overall maximum capacity for the facility remains 135 residents.
Report Facts
Inspection Report — Jun 28, 2019
Complaint Investigation
Date: Jun 28, 2019
Visit Reason
The inspection was conducted as a complaint investigation to assess compliance with 55 Pa.Code Ch. 2600 relating to Personal Care Homes.
Complaint Details
The inspection was triggered by a complaint. The notice was unannounced. No substantiation status is explicitly stated.
Findings
The inspection found violations related to unsecured resident records in the secured dementia care unit. The facility was cited for failing to store resident records in locked or secured containers accessible only to authorized personnel.
Citations (1)
55 Pa.Code 2600.254c requires resident records to be stored in locked or secured containers. Records for residents in the secured dementia care unit were found unlocked, unattended, and accessible in a common area and nurse's office in plain view.
Report Facts
Residents Served: 108
Secured Dementia Care Unit Residents Served: 39
Hospice Current Residents: 7
Inspection Report — May 8, 2019
Annual Inspection
Date: May 8, 2019
Visit Reason
The inspection was conducted as an annual licensing inspection of Oak Leaf Manor North to assess compliance with 55 Pa.Code Ch. 2600 relating to Personal Care Homes.
Findings
Violations were found related to medication storage and medication procedures, including unlocked medications accessible to a resident and lack of a system to investigate and account for missing controlled substances.
Citations (2)
2600.183b: Prescription medications, OTC medications, CAM and syringes were not kept locked. Resident 1 had unlocked medications accessible in her bathroom vanity and was not assessed to self-administer medications.
2600.185b: The home lacked a system to investigate and account for missing controlled substances, including specific medications such as Ativan, Alprazolam, liquid Lorazepam, and Promethazine-Codeine.
Report Facts
Residents Served: 106
Secured Dementia Care Unit Residents Served: 38
Hospice Current Residents: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandi Rendler | Administrator | Named in plan of correction signatures and medication procedure findings |
Notice — Mar 28, 2019
Date: Mar 28, 2019
Visit Reason
This document serves as a renewal notification and license issuance for Oak Leaf Manor North to operate as a Personal Care Home. It informs the facility that an annual onsite inspection will be conducted within the next twelve months as required by state regulations.
Findings
No inspection findings are reported in this document. It is a licensing and renewal communication confirming the issuance of a regular license.
Report Facts
Inspection Report — May 16, 2018
Renewal
Date: May 16, 2018
Visit Reason
The inspection was conducted as an annual licensing renewal inspection with an additional incident trigger at Oak Leaf Manor North.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including deficiencies in fire safety drills, medical evaluations, fire hazard safeguards, and exit door signage. Plans of correction were submitted addressing each violation with timelines and responsible parties.
Citations (5)
55 Pa.Code 2600.132(b) - The last fire safety inspection and drill by a fire safety expert was not conducted annually; last was May 3, 2017.
55 Pa.Code 2600.132(e) - Fire drills during sleeping hours were not held every six months; last drill was April 26, 2018, prior was September 20, 2017.
55 Pa.Code 2600.141(b)(1) - Resident #1's last medical evaluation on April 28, 2018, did not include a list of medications.
55 Pa.Code 2600.144(c)(1) - The home's designated smoking area had six cushions that were not fire resistant and labeled flammable.
55 Pa.Code 2600.233(c) - Directions for operating the home's locking mechanisms were not conspicuously posted near Stairwell Exit Door #15 and Stairwell Exit Door #14.
Report Facts
Number of Residents Served: 89
Number of Current Hospice Residents: 14
Number of Hospice Residents in Past Year: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandi Rendler | Administrator, Executive Director | Named as legal entity representative and involved in plans of correction. |
| Jacqueline L. Rowe | Director | Signed the cover letter for the inspection report. |
Inspection Report — Mar 19, 2018
Complaint Investigation
Date: Mar 19, 2018
Visit Reason
The inspection was conducted as a complaint investigation at Oak Leaf Manor North.
Complaint Details
The inspection was complaint-driven. The violation involved failure to update resident assessments as required. No substantiation status was explicitly stated.
Findings
A violation of 55 Pa.Code Chapter 2600 was found related to resident #1's assessment not reflecting the need for assistance with bathing, dressing, grooming, ambulation, toileting, and transfers. A plan of correction was submitted to address the issue.
Citations (1)
55 Pa.Code 2600.225(c) - Resident #1's assessment dated 6/28/17 did not reflect the resident's need for assistance with bathing, dressing, grooming, ambulation, toileting, and transfers.
Report Facts
Number of Residents Served: 92
Number of Residents Served in Secured Dementia Care Unit: 38
Number of Current Hospice Residents: 8
Number of Hospice Residents in past year: 15
Number of Residents 60 Years or Older: 92
Number of Residents with Mobility Need: 38
Notice — Feb 15, 2018
Date: Feb 15, 2018
Visit Reason
The document serves as a renewal approval for the Personal Care Home license for Oak Leaf Manor North and informs about the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It confirms issuance of a regular license following the renewal application.
Report Facts
Notice — Nov 1, 2017
Date: Nov 1, 2017
Visit Reason
Issuance of a revised license due to the facility's recent adjustment of the use of physical space, reflecting updated secured dementia care unit capacity.
Findings
The revised license indicates a secured dementia care unit licensed capacity of 39 and a total maximum capacity of 135 persons. The expiration date of the license remains unchanged.
Report Facts
Inspection Report — Aug 16, 2017
Renewal
Date: Aug 16, 2017
Visit Reason
The inspection was a licensing inspection conducted by the Pennsylvania Department of Human Services to identify violations related to 55 Pa.Code Chapter 2600 for Personal Care Homes.
Findings
Multiple violations were found including missing fee schedules in resident contracts, incomplete criminal background checks for staff, incomplete staff training documentation, incomplete medical evaluations for residents, and improper documentation of blood glucose measurements. Plans of correction were partially implemented as of the report date.
Citations (5)
Regulation 55 Pa.Code 2600.25(c)(2) - Resident contracts did not contain a fee schedule listing the actual amount of allowable resident charges for the home's available services.
Regulation 55 Pa.Code 2600.51 - Criminal background checks were not completed prior to staff members' first scheduled day of work.
Regulation 55 Pa.Code 2600.65(b) - The home's record of direct care staff training did not include required documentation for initial training of certain staff members.
Regulation 55 Pa.Code 2600.141(a)(2) - The medical evaluation for a resident did not document the health status of the resident.
Regulation 55 Pa.Code 2600.185(a) - The home did not fully implement procedures to document blood glucose level measurements in the resident's Medication Administration Record.
Report Facts
Number of Residents Served: 88
Total Daily Staff: 123
Walking Staff: 92
Number of Residents 60 Years or Older: 85
Number of Residents with Mobility Need: 37
Number of Current Hospice Residents: 5
Number of Hospice Residents in Past Year: 15
Inspection Report — May 30, 2017
Original Licensing
Date: May 30, 2017
Visit Reason
The inspection was conducted as a licensing inspection for a new legal entity operating the facility.
Findings
The facility was found to be in substantial compliance with applicable regulations under 55 Pa.Code Chapter 2600 relating to Personal Care Homes. The licensing inspector was unable to complete a full inspection due to the new legal entity status.
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