Inspection Reports for
Heritage Grove at Penn Hills LLC
7151 SALTSBURG ROAD,, PENN HILLS, PA, 15235
Back to Facility Profile23 Reports
Inspection Report — Jul 30, 2025
Original Licensing
Date: Jul 30, 2025
Visit Reason
The inspection was conducted due to a change in legal entity and as part of the licensing inspection process for Heritage Grove at Penn Hills LLC.
Findings
The facility was found to be in substantial compliance with regulations but had multiple deficiencies including sanitary conditions, hot water temperature exceeding limits, missing emergency telephone numbers, window screens missing, improper food storage, insufficient emergency water supply, and incomplete fire drill records.
Citations (9)
85a - Sanitary conditions were not maintained as ceiling fan vents in multiple resident and staff bathrooms had layers of dust approximately one-eighth inch thick.
89b - Hot water temperature exceeded 120°F in sinks of resident rooms #1, #5, #15, and the staff/visitor bathroom, measuring up to 122.5°F.
91 - Emergency telephone numbers for hospital, police, fire, ambulance, poison control, emergency management, and complaint hotline were not posted near the telephone in the activities room.
92 - A window in a resident room was missing a screen, violating requirements for windows to be in good repair and securely screened.
103g - Food was stored improperly as an unlidded plastic container held opened and unsealed bags of dried pasta in the kitchen dry storage area.
107c - The emergency water supply was insufficient, providing only 50 gallons instead of the required 72 gallons for 24 residents, and lacked a contract for immediate water delivery.
132c - Fire drill records did not indicate problems encountered during drills where full evacuation was not achieved due to resident refusal.
132d - The home lacked fire-safe areas designated in writing by a fire safety expert, and fire drills showed incomplete evacuations with residents not reaching public thoroughfares.
132i - The fire alarm was not set off during a fire drill conducted on 3/25/25 as required.
Report Facts
Residents served: 24
Water temperature: 122.5
Emergency water supply gallons: 50
Required emergency water gallons: 72
Fire drill residents: 18
Residents evacuated: 17
Fire drill residents: 17
Fire drill residents: 21
Residents evacuated: 20
Fire drill residents: 23
Residents evacuated: 22
Inspection Report — Jul 30, 2025
Follow-Up
Date: Jul 30, 2025
Visit Reason
The inspection was conducted as a partial, announced review due to a change in legal entity for the facility.
Findings
The inspection identified multiple deficiencies including sanitary conditions, hot water temperature exceeding limits, missing emergency telephone numbers, window screens in disrepair, improper food storage, insufficient emergency water supply, incomplete fire drill records, evacuation issues, and failure to activate fire alarms during drills. Plans of correction were directed and implemented for all deficiencies.
Citations (9)
Ceiling fan vents in multiple locations had a layer of dust/lint approximately one-eighth of an inch thick.
Hot water temperature at sinks in resident rooms and staff bathroom exceeded 120°F, measuring up to 122.5°F.
Emergency telephone numbers were not posted near the telephone in the activities room.
No screen was present in the right-side window of two windows in a resident room.
Opened and unsealed bags of dried pasta were stored in an unlidded plastic container in the kitchen dry storage area.
Emergency water supply was insufficient with only 50 gallons available for 24 residents requiring 72 gallons, and no contract with a bottled water supplier for emergencies.
Fire drill records did not indicate problems encountered during evacuation, and some drills did not fully evacuate residents due to refusal or other issues.
The home did not have fire safe areas designated in writing by a fire safety expert, and multiple fire drills had incomplete evacuations.
Fire alarm or smoke detector was not set off during a fire drill conducted at 5:20 a.m.
Report Facts
Residents served: 24
Water temperature: 122.5
Water temperature: 121.4
Emergency water supply: 50
Emergency water required: 72
Fire drill residents: 18
Fire drill residents evacuated: 17
Fire drill residents: 17
Fire drill residents: 21
Fire drill residents evacuated: 20
Fire drill residents: 23
Fire drill residents evacuated: 22
Inspection Report — Mar 26, 2025
Complaint Investigation
Date: Mar 26, 2025
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on 03/26/2025, 03/28/2025, and 04/04/2025.
Complaint Details
The inspection was complaint-related and the report indicates no deficiencies or citations were found, implying the complaint was not substantiated.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 17
Current Residents in Hospice: 3
Total Daily Staff: 21
Waking Staff: 16
Resident Mobility Need: 4
Inspection Report — Jan 14, 2025
Complaint Investigation
Date: Jan 14, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation during an unannounced partial inspection.
Complaint Details
The inspection was triggered by a complaint and incident, but no deficiencies or 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: 17
Current Hospice Residents: 3
Residents Age 60 or Older: 26
Residents with Mobility Need: 5
Total Daily Staff: 22
Waking Staff: 17
Inspection Report — Oct 1, 2024
Renewal
Date: Oct 1, 2024
Visit Reason
The inspection was conducted as a renewal inspection of the facility license.
Findings
The inspection identified multiple deficiencies including issues with record confidentiality, quality management, resident personal equipment safety, food labeling and storage, combustible storage, evacuation procedures, and medication administration and labeling. All deficiencies had plans of correction accepted and were implemented by December 23, 2024.
Citations (10)
Privacy coding document listing names of residents was attached to the Licensing Inspection Summary posted in the front lobby.
The home had not conducted a quality management review since a prior date.
Resident had an uncovered enabler bar at the top right side of bed which was not secured and could be pulled out from under the mattress.
Unlabeled and undated 24-ounce bag of Swiss cheese slices and 2-pound bag of chopped spinach found in kitchen refrigerator.
Unlabeled and undated bag of breadsticks and 2-pound bag of chicken cubes found in kitchen freezer.
Combustible and flammable materials stored near heat sources in mechanical room.
Evacuation drills exceeded the safe evacuation time of 3 minutes and 45 seconds; residents did not evacuate to outside of building during one drill.
Prescription medication administered by staff not certified to administer the medication.
Two discontinued boxes of medication found in medication room refrigerator, one opened and one with unopened pens of different dosages.
Pharmacy labels for residents' medications did not accurately reflect prescribed dosage and instructions for administration.
Report Facts
Residents Served: 22
Current Hospice Residents: 5
Residents with Mobility Need: 9
Residents Age 60 or Older: 22
Staffing Hours - Total Daily Staff: 31
Staffing Hours - Waking Staff: 23
Inspection Report — Jun 22, 2023
Complaint Investigation
Date: Jun 22, 2023
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulatory requirements at Brookdale Penn Hills.
Complaint Details
The inspection was complaint-driven as indicated by the reason for inspection and the unannounced partial inspection on 06/22/2023.
Findings
The inspection identified deficiencies related to staff training in first aid and CPR, direct care staff providing unsupervised services without completing required training, and issues with discharge or transfer procedures including failure to provide required 30-day notice and lack of consultation with appropriate agencies when a resident's functional level declined.
Citations (4)
Direct care staff persons were not trained in first aid and certified in obstructed airway techniques and CPR during certain shifts despite having 22 residents present.
Direct care staff person B provided unsupervised direct care services without successfully completing and passing the Department-approved direct care training course and competency test.
The home discharged a resident without issuing a 30-day advance written notice and without certification that delay in discharge would jeopardize health or safety.
The home discharged a resident due to functional decline without consultation with an appropriate assessment agency or the resident’s physician to determine need for a higher level of care.
Report Facts
Residents present: 22
Residents served: 19
Total daily staff: 27
Waking staff: 20
Current hospice residents: 3
Residents with mobility need: 8
Residents aged 60 or older: 19
Inspection Report — Dec 20, 2022
Renewal
Date: Dec 20, 2022
Visit Reason
The inspection was conducted as a full, unannounced visit for renewal and complaint reasons on 12/20/2022 and 12/21/2022.
Findings
The facility was found to have multiple deficiencies including a direct care staff member lacking required qualifications at hire, incomplete annual furnace inspections, incomplete and inaccurate fire drill records, and fire drill evacuation times exceeding the maximum allowed. The submitted plan of correction was determined to be fully implemented as of the follow-up date.
Citations (4)
Direct care staff person hired without a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
Six of seven gas furnaces had not been inspected by a professional furnace cleaning company or trained maintenance staff since 12/10/2019.
Fire safety inspection and fire drill documentation were incomplete or missing for multiple dates, including missing details such as evacuation times, exit routes, number of residents and staff participating, and operability of alarms.
Fire drill evacuation times exceeded the maximum evacuation time of 6 minutes, with one drill taking 8 minutes and 56 seconds.
Report Facts
Residents Served: 24
Number of Furnaces: 7
Furnaces Not Inspected: 6
Fire Drill Evacuation Time: 536
Residents Present at Fire Drill: 26
Residents Evacuated at Fire Drill: 23
Inspection Report — Aug 30, 2021
Renewal
Date: Aug 30, 2021
Visit Reason
The inspection was conducted as a renewal licensing inspection of the facility Brookdale Penn Hills on 08/30/2021 through 09/02/2021.
Findings
The inspection identified multiple deficiencies including breaches in record confidentiality, improper storage of poisonous materials, trash management issues, furniture repair needs, food contamination and outdated food, obstructed egress due to locked doors, emergency procedure posting issues, menu change notification failures, expired medications, and inoperable bedside lamps. Plans of correction were accepted and implemented for all deficiencies.
Citations (11)
Resident privacy coding document and resident rosters containing confidential information were accessible in public areas.
Clear liquid in an unlabeled 32-ounce spray bottle used for cleaning was found.
Uncovered dumpster with trash and a mattress sticking out, with trash scattered around.
Broken and detached bottom hinge on a kitchen cabinet door.
Dirty rims and handles on plastic powder sugar and cinnamon shakers in kitchen cabinet.
Multiple undated foods stored in the freezer including raw chicken, jumbo pasta shells, and hot sausage links.
Front and rear doors were locked with keypad access not posted and not all residents could independently open them.
Municipality’s emergency procedures were kept in administrator’s office, not a conspicuous and public place.
Menu changes were not posted in a conspicuous and accessible place prior to meals.
Multiple expired medications found in the home’s van first aid kit.
Bedside lamp not within reach and tap light on bed’s headboard not working in bedroom 5.
Report Facts
Inspection Dates: 4
Total Daily Staff: 24
Waking Staff: 18
Residents Served: 19
Hospice Residents: 2
Residents 60 Years or Older: 19
Residents with Mobility Need: 5
Expired Medications: 3
Expired Medications: 10
Expired Medications: 10
Notice — Mar 19, 2021
Date: Mar 19, 2021
Visit Reason
The document serves as a renewal notification and license issuance for the Personal Care Home, Brookdale Penn Hills, following receipt of the renewal application dated December 30, 2020. It also advises that an annual onsite inspection will be conducted within the next twelve months.
Findings
No inspection findings are reported in this document. It confirms issuance of a regular license and states that enforcement action will be taken if noncompliance is found during future inspections.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter. |
Notice — Feb 7, 2020
Date: Feb 7, 2020
Visit Reason
This document serves as a renewal notification and issuance of a regular license for the Brookdale Penn Hills Personal Care Home pursuant to Title 55, PA Code, Chapter 2600.
Findings
The Department confirms receipt of the renewal application and states that an onsite annual inspection will be conducted within the next twelve months as required by regulation. No findings or deficiencies are reported in this document.
Inspection Report — May 31, 2019
Renewal
Date: May 31, 2019
Visit Reason
The inspection was a renewal inspection conducted by the Department’s Bureau of Human Services Licensing to assess compliance with 55 Pa. Code Ch. 2600 for the Personal Care Home.
Findings
Multiple violations were found related to staff certification, training, sanitation, safety, medical evaluations, and medication labeling. Plans of correction were submitted and partially implemented as of August 7, 2019.
Citations (12)
Regulation 2600.18: Staff member A prepared and served meals without ServeSafe certification, and no staff were ServeSafe certified at the time.
Regulation 2600.65.g: Direct care staff person B did not receive annual emergency preparedness training during the 2018 training year.
Regulation 2600.82.c: Poisonous materials were unlocked and accessible, including spray bottles with cleaning chemicals.
Regulation 2600.85.a: No paper towels, mechanical air blower, or other hand drying means were available in bathrooms of bedrooms #14 and #17.
Regulation 2600.85.d: A trash can in a common bathroom was half filled with trash and had an open lid that was battery operated and nonfunctional.
Regulation 2600.92: A 6" by 2" tear was found in the window screen in the Discovery Room.
Regulation 2600.101.j: The bedside lamp for resident #1 was placed 3.5 to 4 feet from the bed, making it unreachable.
Regulation 2600.132.g: Fire drills were routinely held during sleeping hours but not at varied times or days as required.
Regulation 2600.141.a: Resident #1's medical evaluation lacked height, body positioning/movement, special health and dietary needs, and allergy information.
Regulation 2600.141.b.1: Resident #3's most recent medical evaluation was missing special health and dietary needs.
Regulation 2600.171.b5: The first aid kit in the facility's van lacked eye coverings and a thermometer.
Regulation 2600.184.a: The pharmacy label for resident #3's Losartan Potassium medication did not match the physician's order and required clarification.
Report Facts
Residents Served: 15
Current Hospice Residents: 2
Total Daily Staff: 15
Waking Staff: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Judith Carrabbia | Executive Director | Signed multiple plans of correction and involved in staff retraining and policy implementation |
| Judy Carrabbia | Executive Director | Signed plan of correction for fire drill scheduling and medical evaluation review |
Inspection Report — Mar 26, 2019
Renewal
Date: Mar 26, 2019
Visit Reason
The document is a renewal license certificate and letter for Brookdale Penn Hills Personal Care Home, issued to authorize operation for a maximum capacity of 26 residents. The letter states the Department will conduct an annual onsite inspection within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It is a license renewal certificate and accompanying letter confirming receipt of the renewal application and outlining future inspection requirements.
Report Facts
Inspection Report — Feb 25, 2019
Complaint Investigation
Date: Feb 25, 2019
Visit Reason
The inspection was conducted as a complaint investigation following a complaint regarding abuse involving resident #1.
Complaint Details
The complaint involved an allegation of abuse to resident #1. Protective services investigated on 2/7/19. The facility failed to report the incident timely, submitting the report only on 2/25/19.
Findings
The facility failed to report an allegation of abuse within the required 24-hour timeframe and did not include required diagnoses in resident assessments. Support plans were found inaccurate or incomplete for residents #1 and #2, with corrective actions planned and partially implemented.
Citations (4)
Regulation 2600.16(c): The home did not report the allegation of abuse or submit an incident report to the Department until 2/25/19, after protective services investigated on 2/7/19.
Regulation 2600.225(c): The assessment for resident #1 did not include diagnoses of Alzheimer's disease, gummata, ulcers of yaws, glaucoma, heart disease, and depression as indicated on the resident’s medication list.
Regulation 2600.225(c): The assessment for resident #2 did not address the support plan assistance with showers, despite hospice providing shower assistance.
Regulation 2600.227(c): Resident #2's support plan did not address services to assist during periods of irritability and was updated after reassessment found no irritability problem.
Report Facts
Number of Residents Served: 18
Total Daily Staff: 27
Waking Staff: 20
Number of Current Hospice Residents: 3
Number of Hospice Residents in past year: 8
Number of Residents Age 60 or Older: 17
Number of Residents with Mobility Need: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Judy Carrabbia | Executive Director | Named in plan of correction and corrective actions related to incident reporting and staff training. |
| Lisa Flinner-Alman | Department representative conducting the inspection on 2/25/19. | |
| Vicki Pfaff | Department representative conducting the inspection on 2/25/19. |
Inspection Report — May 17, 2018
Renewal
Date: May 17, 2018
Visit Reason
The inspection was a renewal visit conducted by the Department's Bureau of Human Services Licensing to assess compliance with 55 Pa. Code Chapter 2600 for Personal Care Homes.
Findings
Multiple violations were found related to staff training hours, fire safety training, medication administration, fire hazard lint removal, smoking area safety, and medication record keeping. Plans of correction were submitted with partial or full implementation status noted.
Citations (9)
Regulation 2600.65(e) - Direct care staff person A received only 7.5 hours of annual training instead of the required 12 hours during the 2017 training year.
Regulation 2600.65(f) - Direct care staff person B did not receive training in medication self-administration, resident needs, and personal care service during the 2017 training year.
Regulation 2600.65(g) - Direct care staff person A did not receive fire safety training completed by a fire safety expert during the 2017 training year.
Regulation 2600.105(g)(1) - A ball of lint approximately 3.5 inches in diameter was found behind the lint trap in the far right clothes dryer in the laundry area.
Regulation 2600.144(c)(1) - Two seat cushions in the home's designated smoking area were not fire resistant.
Regulation 2600.144(c)(2) - The home's designated smoking area was approximately 4 feet from the rear exit, not a safe distance from heat sources.
Regulation 2600.183(b) - An unlocked, unattended bottle of Polyethylene Glycol was found on top of resident #1's dresser.
Regulation 2600.185(a) - Resident #2's prescribed medication Guaifenesin AC syrup was not available in the home for administration.
Regulation 2600.187(a) - Resident #2's medication administration record did not include the correct frequency of administration for Senexon tablets.
Report Facts
Number of Residents Served: 17
Staff Training Hours Required: 12
Staff Training Hours Received: 7.5
Lint Ball Diameter: 3.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Judy Carrabbia | Administrator | Named as Administrator and Legal Entity Representative signing plans of correction. |
| Judith Carrabbia | Legal Entity Representative | Signed multiple plans of correction and approval forms. |
| Joseph Eveges | Inspector conducting the violation report and inspection. |
Inspection Report — Dec 11, 2017
Renewal
Date: Dec 11, 2017
Visit Reason
The document is a renewal application and license issuance for Brookdale Penn Hills Personal Care Home. The Department of Human Services will conduct an onsite inspection within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It is a license renewal notice confirming the issuance of a regular license.
Inspection Report — Jun 5, 2017
Annual Inspection
Date: Jun 5, 2017
Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing inspection and included renewal and complaint investigation components.
Complaint Details
The inspection included a complaint investigation component; however, no substantiation status was explicitly stated in the report.
Findings
The inspection found multiple violations of 55 Pa.Code Chapter 2600 related to resident privacy, use of terminology, medication administration, and resident assessments. Plans of correction were submitted with partial implementation progress noted.
Citations (6)
Regulation 2600.17: Resident privacy code page was posted on the bulletin board, violating confidentiality requirements.
Regulation 2600.18: The term 'assisted living' was used improperly in facility documents instead of 'personal care home'.
Regulation 2600.183(d): Expired medication packets and improperly labeled medication devices were found in resident medication supplies.
Regulation 2600.185(a): Resident's glucometer was not calibrated to current date and time, and medication administration records had incomplete blood glucose readings.
Regulation 2600.187(a): Medication administration records lacked required details including medication names, dosages, and administration times.
Regulation 2600.225(c): Resident assessment was not updated to reflect diet changes and hospice services in a timely manner.
Report Facts
Number of Residents Served: 21
Number of Current Hospice Residents: 5
Number of Hospice Residents in past year: 10
Total Daily Staff: 29
Walking Staff: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Judith Carrobbio | Executive Director | Named in multiple plans of correction and signatures on pages 3-9. |
Inspection Report — Dec 28, 2016
Routine
Date: Dec 28, 2016
Visit Reason
The Department of Human Services licensing representatives conducted an inspection of the Brookdale Penn Hills facility on December 28, 2016.
Findings
No regulatory violations were identified as a result of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susie Pollock | Regional Licensing Director | Signed the inspection report letter. |
Notice — Dec 8, 2016
Date: Dec 8, 2016
Visit Reason
This document serves as a renewal notification and license issuance for Brookdale Penn Hills Personal Care Home. It informs the facility of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license following the renewal application.
Inspection Report — Jul 18, 2016
Renewal
Date: Jul 18, 2016
Visit Reason
The inspection was conducted as an annual licensing inspection with reasons for inspection including renewal and incident.
Findings
Multiple violations of Pennsylvania Code Chapter 2600 were found, including unsafe storage of poisonous materials, missing emergency phone numbers, combustible materials near heat sources, and incomplete pre-admission screening documentation. Plans of correction were submitted with partial implementation progress noted.
Citations (4)
Regulation 2600.82(c): Poisonous materials were not kept locked and inaccessible to residents, with lighter fluid containers left unattended and accessible on the back patio.
Regulation 2600.91: Emergency telephone numbers were not posted on or near the cordless phone in resident #3's bedroom and the posted numbers did not include poison control.
Regulation 2600.125(a): Combustible and flammable materials, including lint, paper towels, wash cloths, and broom handles, were located near heat sources in the laundry and mechanical rooms.
Regulation 2600.224(a): The pre-admission screening form was not completed prior to resident #2's admission as required.
Report Facts
Number of Residents Served: 23
Total Daily Staff: 35
Waking Staff: 26
Number of Current Hospice Residents: 2
Number of Hospice Residents in Past Year: 10
Number of Residents Age 60 or Older: 23
Number of Residents with Mobility Need: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Judy Carrabba | Administrator | Named as legal entity representative and administrator on multiple violation pages |
| Cliff Hultquist | Named as inspector on page 2 and violation reports | |
| Joseph Evegos | Named as inspector on page 2 |
Notice — Feb 18, 2016
Date: Feb 18, 2016
Visit Reason
The Department of Human Services issued a notice of intent to assess a fine for regulatory violations related to advertising as an Assisted Living residence without proper licensure.
Findings
Brookdale of Penn Hills was found to be advertising as an Assisted Living residence without being licensed as such, violating 55 Pa.Code Chapter 2600. A fine of $720 was assessed for the period from February 19, 2016 through March 4, 2016.
Citations (1)
55 Pa.Code §2600.18: The facility advertised assisted living services without being licensed as an assisted living residence, violating state regulations.
Report Facts
Fine amount: 720
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacob Herzing | Enforcement Manager | Named as contact for appeals and inspection representative. |
| Matthew J. Jones | Director | Signed the notice letter assessing the fine. |
Inspection Report — Jan 29, 2016
Date: Jan 29, 2016
Visit Reason
The inspection was conducted as an interim document review related to a violation concerning the improper use of the term 'Assisted Living' in facility materials.
Findings
The facility was found in violation of 55 Pa.Code Chapter 2600 for advertising assisted living services without proper licensure. The violation involved use of the term 'Assisted Living' contrary to state regulations.
Citations (1)
55 Pa.Code § 2600.18: The facility advertised assisted living services without being licensed as an assisted living residence, violating state regulations.
Report Facts
Fine per resident per day: 3
Calculated Fine per day: 48
Mandated Correction Period: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matthew J. Jones | Director | Signed letter regarding violation and enforcement |
| Jacob Herzing | Enforcement Manager | Contact for plan of correction submission and inspection |
Report — December 23, 2025
December 23, 2025
Report — December 3, 2025
December 3, 2025
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