Pennsylvania Department of Health
HERITAGE RIDGE SENIOR LIVING AT WINDY HILL
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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HERITAGE RIDGE SENIOR LIVING AT WINDY HILL - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: - Component: -- - Tag: 0000

Based on an Emergency Preparedness Survey completed on June 15, 2026, at Heritage Ridge Senior Living at Windy Hill, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: BUILDING 03 - Component: 03 - Tag: 0000

Facility ID# 164302
Component 03
Building 03

Based on a Medicare/Medicaid Recertification Survey completed on June 15, 2026, it was determined that Heritage Ridge Senior Living at Windy Hill was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one story, Type V (000), unprotected, wood frame building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Doors with Self-Closing Devices:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

Doors with Self-Closing Devices
Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

Observations:
Name: BUILDING 03 - Component: 03 - Tag: 0223

Based on observation and interview, it was determined the facility failed to maintain doors with self-closing devices, affecting one of one floor.

Findings include:

1. Observation on June 15, 2026, at 10:40 am, revealed the 1st floor, Laundry door failed to fully close and latch into frame when tested.

Exit interview with the Facility Administrator and the Facilities Manager on June 15, 2026, at 11:45 am, confirmed the door failed to fully close and latch.

Plan of Correction - To be completed: 07/09/2026

The 1st floor laundry room was inspected and diagnosed as to why it failed to close properly. The door was checked for misalignment between the door and the door frame. Staff examined the latch, hinges, and other related hardware for wear and tears. Upon review of these, maintenance found that screws were loose causing the door to catch upon closing, WD-40 was also applied to the hinges and latch. After taking these steps, the door proceeds to latch fully and appropriately.

Follow-up training was presented to the maintenance staff on proper door adjustment repairs and techniques to ensure future resolutions of similar occurrences.

A new inspection program was introduced for all doors to continue to prevent recurrence of similar issues. All door closures will be monitored and inspected on a weekly basis to ensure ongoing compliance and functionality. Any findings from these inspections will be presented to Quality Control Assurance Performance Improvement committee for any further recommendations or discussions.

NFPA 101 STANDARD Cooking Facilities:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Observations:
Name: BUILDING 03 - Component: 03 - Tag: 0324

Based on documentation review and interview, the facility failed to maintain cooking facilities in one instance, affecting two of two floors.

Findings include:

1. Document Review on June 15, 2026, between 9:15 am, and 10:15 am, revealed during the semi-annual kitchen suppression inspections, it was stated on 3/6/2026 and 9/16/2025, that the make-up air system failed to shut down during testing. The facility was advised they needed an electrician, Lightning Electrical was contacted and was on site in May of 2026. The facility is still working with Lightning Electrical on fixing the issue, however at the time of the survey this condition still remains.

Exit interview with the Facility Administrator and the Facilities Manager on June 15, 2026, at 11:45 am, confirmed the kitchen suppression deficiency.

Plan of Correction - To be completed: 07/09/2026

During a recent Annual required inspection it was noted that the kitchen suppression systems make up air was failing to work properly. Initial evaluation by Lightning Electric Company, prior to the Annual survey, resulted in insufficient knowledge of the problem and therefore resulted in a new company being contacted to come in and make the necessary repairs. It was found that the microswitch had failed and needed to be replaced. A new Company known as ASAP Electric was brought into the facility and found the microswitch wasn't functioning properly and a control box needed to be installed.

The control box was ordered and the date of completion for this repair will be done by 7/17/2026. Upon completion of the job by ASAP Electric company, the makeup air will be now shutting down when the suppression unit is tripped.

Maintenance will be present during the repairs when made on July 17th and will be educated on correct procedures to follow upon identification of an infraction of the system.

Initial comments:Name: BUILDING 04 - Component: 04 - Tag: 0000

Facility ID# 164302
Component 04
Building 04

Based on a Medicare/Medicaid Recertification Survey completed on June 15, 2026, it was determined that Heritage Ridge Senior Living at Windy Hill was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a two story, Type II (111), protected, noncombustible building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Corridor - Doors:

Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Observations:
Name: BUILDING 04 - Component: 04 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain two corridor openings, affecting two of two floors.

Findings include:

1. Observation on June 15, 2026, at between 11:07 am, and 11:09 am, revealed the following:

a. At 11:07 am, 2nd floor, Resident Room 407 door failed to latch into frame.
b. At 11:09 am, 2nd floor, Resident Room 410 door failed to latch into frame.

Exit interview with the Facility Administrator and the Facilities Manager on June 15, 2026, at 11:45 am, confirmed the corridor doors failed to latch when tested.

Plan of Correction - To be completed: 07/09/2026

An inspection was conducted in rooms 407 and 410 to diagnose why the handles failed to latch into the door frame. Upon review, it was identified that the inside mechanics of the door handles were fractured and needed to be replaced. Adjustments were made and upon further testing both doors securely latch and open without delay.

Implemented an inspection program for all door handles to be conducted monthly to prevent reoccurrences of similar issues. The inspection will be put into our TELS system as a preventative maintenance to monitor and track compliance with inspection. Findings from the inspection conducted will be brought to the attention of the Quality Assurance Performance Improvement committee for any further discussions or recommendations.

NFPA 101 STANDARD HVAC:

HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2

Observations:
Name: BUILDING 04 - Component: 04 - Tag: 0521

Based on observation and interview, the facility failed to maintain Heating, Ventilating, and Air Conditioning (HVAC) system ductwork in one location, affecting two of two floors.

Findings include:

1. Observation on June 15, 2026, at 10:52 am, 2nd floor, revealed that an HVAC duct was open and venting in the interstitial space above the ceiling, inside the soiled work room.

Exit interview with the Facility Administrator and the Facilities Manager on June 15, 2026, at 11:45 am, confirmed the duct was venting above the ceiling.

Plan of Correction - To be completed: 07/09/2026

Upon walking through the life safety survey, it was discovered to have had an open duct in the Soiled Linen room on the 2nd floor above the ceiling. After investigating the matter, it was found that the duct was not sealed properly upon new duct work being installed previously. The old duct was sealed and caulked around with the fire-retardant caulk and the fire-retardant spray foam insulation.

A facility wide inspection was done above all ceiling tiles where ducts would be located to ensure no openings were found.

NFPA 101 STANDARD Fire Drills:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7

Observations:
Name: BUILDING 04 - Component: 04 - Tag: 0712

Based on documentation review and interview, it was determined the facility failed to perform fire drills on a random basis, affecting two of two floors, within three components.

Findings include:

1. Document Review on June 15, 2026, between 9:15 am, and 10:15 am, revealed that 11 of 12 quarterly fire drills for the last 12 months, were conducted within the last week of the month.

Exit interview with the Facility Administrator and the Facilities Manager on June 15, 2026, at 11:45 am, confirmed the fire drills were not conducted on a random basis.

Plan of Correction - To be completed: 07/09/2026

Upon briefing with Surveyor, it was noted that fire drills were not being conducted on a random basis as they should be and were being done on the last few days of the month.

Upon review, a new system was put into place regarding fire drills conducted in the future.

If a fire drill is conducted on the last day of the month, the following will be done within the first week of the next month, then the following week of the month after that. This will ensure that they stay random and compliant with the life safety guidelines.

Training was provided to maintenance staff on the new process of conducting more random fire drills monthly.

Initial comments:Name: BUILDING 05 - Component: 05 - Tag: 0000

Facility ID# 164302
Component 05
Building 05

Based on a Medicare/Medicaid Recertification Survey completed on June 15, 2026, at Heritage Ridge Senior Living at Windy Hill, it was determined there were no deficiencies identified under the requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a two story, Type V (111), protected, wood frame building, that is fully sprinklered.

Plan of Correction:

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