Inspection Reports for
Heartland Retirement Personal Care Home
46 ELEMENTARY LANE, BOX 210,, WOOLRICH, PA, 17779
Back to Facility Profile21 Reports
Inspection Report — Dec 26, 2024
Follow-Up
Date: Dec 26, 2024
Visit Reason
The inspection was conducted as a follow-up review of a previously submitted plan of correction related to an incident at the facility.
Findings
The Pennsylvania Department of Human Services determined that the submitted plan of correction was fully implemented and compliance was maintained. The deficiency involved a Resident Initial Assessment and Support Plan (RASP) that was not signed by the assessor, resident, or power of attorney, which has since been corrected.
Citations (1)
Resident Initial Resident Assessment and Support Plan (RASP) was not signed by the assessor, the resident, or the power of attorney.
Report Facts
Residents Served: 10
Current Hospice Residents: 1
Total Daily Staff: 11
Waking Staff: 8
Inspection Report — Oct 3, 2024
Renewal
Date: Oct 3, 2024
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 10/03/2024 to review compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including missing CO2 monitor by the fireplace, incomplete administrator training hours, uncovered bed enabler posing entrapment hazard, unlabeled leftover food items, combustible storage hazards, lack of overnight fire drills, incomplete medical evaluation documentation, medication administration record errors, narcotic count sheet issues, late resident initial assessment, and incomplete support plan documentation for a mobility device. Plans of correction were accepted with proposed completion dates mostly by 10/30/2024 and implementation dates by mid-November 2024.
Citations (10)
CO2 monitor was not located in the living room where there was a fireplace present.
Staff Member A only completed 19 hours of the required 24 hours of administrator training for the training year 2023.
Resident 1’s bed enabler was observed uncovered presenting a possible entrapment hazard.
Leftover food items including half a hoagie, pumpkin pie, and Raisin Bran were not labeled with dates.
A washcloth was found in the laundry room behind the dryer near the exhaust vent posing a potential fire hazard.
No overnight fire drills had been completed in the home within the last 6 months as of 10/03/2024.
Resident 2’s medical evaluation documentation was incomplete; medication section indicated 'see attached' but no documentation was attached.
Medication Administration Record (MAR) errors due to staff incorrectly transcribing blood glucose test results and missing narcotic count documentation.
Resident 2’s initial assessment was completed more than 15 days after admission.
Resident 1’s support plan did not reflect the specific need, intended use, risks, or device identification for a bedside mobility device.
Report Facts
Residents Served: 10
Administrator Training Hours Completed: 19
Administrator Training Hours Required: 24
Bed Enabler Opening Size: 17
Bed Enabler Opening Size: 5
Fire Drill Frequency: 6
Medication Blister Pack Count: 12
Unaccounted Doses: 9
Inspection Report — Aug 15, 2023
Renewal
Date: Aug 15, 2023
Visit Reason
The inspection visit was conducted for renewal and complaint reasons as indicated in the inspection information section.
Findings
The inspection identified multiple deficiencies including failure to change and date CO2 monitor batteries annually, missing and unsigned resident contracts, insufficient administrator staffing hours, incomplete annual training, damaged furniture and equipment, inadequate emergency water supply, difficult-to-open exit doors, unposted menu changes, lack of resident education on medication refusal rights, and failure to conduct resident activities as posted.
Citations (11)
The home did not change and date the batteries in the home's CO2 monitor on an annual basis.
The resident home contract for resident #1 could not be found in the home.
The resident home contract for resident #2 was not signed by the resident.
Staff A is not completing 20 administrator hours per week; only 12 hours were completed during a specified week.
The administrator completed only 7.75 hours of required annual training in 2022 instead of 24 hours.
PTAC unit in room 11 was damaged and left with a large gap needing repair.
The home did not maintain a 3-day supply of emergency drinking water; only 13 gallons were available instead of 42 gallons required.
The emergency exit door next to room 206 would not open without excessive force.
A change to the menu was not posted in a conspicuous place for residents on 8/15/23 for breakfast and lunch.
No documentation that resident #1 was educated on the right to question or refuse medication.
Activities posted on the calendar were not being conducted as determined through resident interviews.
Report Facts
Residents Served: 14
Administrator Staffing Hours: 12
Required Administrator Hours: 20
Annual Training Hours Completed: 7.75
Required Annual Training Hours: 24
Emergency Water Supply Required (gallons): 42
Emergency Water Supply Available (gallons): 13
Inspection Report — Jul 19, 2022
Renewal
Date: Jul 19, 2022
Visit Reason
The inspection was conducted as a full, unannounced visit for renewal and complaint reasons on 07/19/2022.
Findings
The report found multiple deficiencies including missing resident signatures on contracts, obstructed egress doors, lack of annual fire safety inspections and drills, absence of a written maximum safe evacuation time, incomplete medical evaluations, incomplete medication records, and incomplete preadmission screening forms. All deficiencies had plans of correction submitted and were implemented by 03/09/2023.
Citations (7)
Resident #1's home contract was not signed by the resident.
Exit door F located in the hallway next to the dining and medication room did not open freely.
The home did not have an observed fire drill and fire safety inspection by a fire safety expert completed by December 31, 2021.
The home does not have a maximum safe evacuation time specified in writing within the past year by a fire safety expert and exceeded evacuation time of 2 minutes 30 seconds during multiple drills.
Resident #1's medical evaluation did not contain height, weight, temperature, and body positioning.
Medication Administration Record for resident #2 did not indicate a diagnosis or purpose for medications.
Resident #2's preadmission screening form did not indicate primary language, ability to self medicate, and medical, psychological, and behavioral diagnosis.
Report Facts
Residents Served: 10
Evacuation Time: 7
Evacuation Time Exceeded: 2.5
Notice — Jun 30, 2021
Date: Jun 30, 2021
Visit Reason
This document serves as a license renewal notification and certificate of compliance for Heartland Retirement Personal Care Home, confirming the facility's authorized capacity and informing about the requirement for an annual onsite inspection within the next twelve months.
Findings
The Department has issued a regular license in response to the renewal application and advises that an annual inspection will be conducted within the next twelve months. Enforcement action will be taken if noncompliance is found during the inspection.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the license renewal notification letter. |
Inspection Report — Jun 23, 2021
Renewal
Date: Jun 23, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the Heartland Retirement Personal Care Home to assess compliance with licensing requirements.
Findings
The inspection identified deficiencies related to failure to provide an itemized refund to a resident's family, difficulty opening an emergency exit door, and incomplete resident records regarding a resident's death. Plans of correction were accepted and implemented.
Citations (3)
Failure to send the resident's family an itemized account of resident #1's refund within 30 days of discharge.
The emergency exit door closest to resident room #16 was difficult to open on the first attempt.
Resident #1's record did not contain the reason for death, death certificate, or hospital records for the hospital stay.
Report Facts
Residents Served: 9
Total Daily Staff: 10
Waking Staff: 8
Inspection Report — Apr 6, 2021
Routine
Date: Apr 6, 2021
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 15, 2020
Date: May 15, 2020
Visit Reason
This document serves as a renewal notification and license issuance for Heartland Retirement Personal Care Home. It informs the facility that an 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 confirms the issuance of a regular license following the renewal application.
Report Facts
Inspection Report — Apr 2, 2020
Renewal
Date: Apr 2, 2020
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on April 2 and 3, 2020.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report — Mar 5, 2020
Renewal
Date: Mar 5, 2020
Visit Reason
The inspection was a full renewal and complaint investigation visit conducted on March 5, 2020, to assess compliance with applicable regulations and verify correction of prior deficiencies.
Findings
The facility was found to have multiple violations including issues with carbon monoxide detector batteries, resident privacy due to camera placement, training deficiencies in medication administration, improper storage of poisonous materials, incomplete fire department notification, failure to conduct monthly fire drills properly, inadequate designated meeting place during fire drills, incomplete medical evaluations, medication administration training gaps, incomplete resident assessments, and outdated resident photographs. Plans of correction were submitted and approved with implementation status marked as completed.
Citations (11)
2600.18: Carbon monoxide detector batteries were dated 1/17/19 and not changed annually as required by The Care Facility Carbon Monoxide Standards Act.
2600.42s: Cameras located in common areas recorded residents, violating residents' privacy rights during bathing, dressing, changing, and medical procedures.
2600.65f: Direct care staff member A hired 9/6/17 did not receive required annual training in medication self-administration and safe management techniques for 2019.
2600.82a: An unlabeled bottle of bleach was found on the kitchen window sill without original manufacturer instructions.
2600.124: The notice to the fire department did not include the home's capacity or mobility needs of residents, and 2 residents require evacuation assistance.
2600.132a: An unannounced monthly fire drill was conducted on 1/30/20, but staff member C did not pull the fire alarm and was unaware of the drill.
2600.132h: Residents were not evacuated to the designated meeting place during the fire drill due to weather conditions, and staff did not ensure proper evacuation procedures.
2600.141a: Resident #1's DME dated 12/9/19 lacked documentation for pulse, self-administration ability, and cognitive functioning.
2600.182b: Staff member C had not completed medication administration training and was administering medications outside approved hours; a new employee was hired and scheduled for certification.
2600.225c: Resident #1's RASP dated 12/12/19 was incomplete with unchecked assessment boxes and missing notes on personal needs.
2600.252: Resident #1 and #2's photographs were outdated, taken over 2 years ago, risking emergency identification issues.
Report Facts
Residents Served: 11
Residents requiring assistance to evacuate: 2
Notice — Mar 18, 2019
Date: Mar 18, 2019
Visit Reason
This document serves as a renewal notification and license issuance for Heartland Retirement Personal Care Home following receipt of a renewal application dated March 15, 2019.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license and advises that an annual onsite inspection will be conducted within the next twelve months.
Inspection Report — Mar 1, 2019
Renewal
Date: Mar 1, 2019
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 of 55 Pa. Code Chapter 2600 were found, including failure to post the current license inspection summary, resident privacy breaches, incomplete fire drill records, missing emergency phone numbers, incomplete staff training, and late medical evaluations. Plans of correction were partially implemented with adequate progress noted.
Citations (8)
Regulation 2600.3(c): The personal care home did not post the current license inspection summary in a conspicuous place as required.
Regulation 2600.17: The license inspection summary posted contained resident privacy coding, exposing confidential resident information.
Regulation 2600.29(a)(11): The home did not provide an itemized written account of resident funds or refunds owed after a resident's passing.
Regulation 2600.65(f): An ancillary staff person did not receive required annual training for emergency preparedness, resident rights, protective services, falls prevention, and new populations served.
Regulation 2600.91: Emergency phone numbers were not posted near two portable phones in resident room #10.
Regulation 2600.132(c): Fire drill logs did not accurately reflect resident evacuation during a drill; records showed discrepancies in resident counts and hospice status.
Regulation 2600.132(e): The home conducted only one sleep time fire drill in the past 12 months, not meeting the requirement of every 6 months.
Regulation 2600.141(a)(1): Resident medical evaluations were not completed within required timeframes prior to admission or annually, with delays of up to 75 days and 18 days noted.
Report Facts
Number of Residents Served: 8
Total Daily Staff: 8
Waking Staff: 6
Number of Deficiencies: 8
Inspection Report — Mar 28, 2017
Renewal
Date: Mar 28, 2017
Visit Reason
The document is a renewal application and license issuance for Heartland Retirement Personal Care Home. The Department will conduct an onsite inspection within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It serves as a license renewal notification and certificate of compliance.
Inspection Report — Mar 1, 2017
Renewal
Date: Mar 1, 2017
Visit Reason
The inspection was an annual licensing inspection conducted as a renewal of the facility's license.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including privacy breaches, missing required posters and detectors, incomplete resident contracts, unsanitary conditions, blocked egress routes, incomplete medical evaluations, and expired or missing resident documentation. Plans of correction were partially implemented at the time of the report.
Citations (10)
The License Inspection Summary was posted with resident privacy coding still attached, violating resident confidentiality.
The home lacked a required PA Department of Health influenza poster and carbon monoxide detectors within 15 feet of gas fireplaces.
Resident contract for resident #3 did not include a fee schedule as required.
Animal feces were found in a child's wading pool filled with sand on the back porch of the home.
Stacked folding chairs and activity supplies blocked egress routes from the dining room and beauty shop, impeding emergency evacuation.
The DME for residents #1 and #2 did not indicate blood pressure, temperature, or date of evaluation as required.
Resident #3's and #4's pre-admission forms were incomplete, missing key elements such as last name and medical diagnoses.
The summary and determination sections of residents #3 and #4's initial RASP forms were not completed.
The summary and determination sections of residents #1 and #2's annual RASP forms were incomplete.
Resident #1's photo on file was expired and resident #3's record lacked identifying marks as required.
Report Facts
Number of Residents Served: 14
Total Daily Staff: 15
Waking Staff: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Callahan | Owner/Administrator, CEO/Admin | Named in multiple findings and signed plans of correction |
| Jacqueline L. Rowe | Director | Signed cover letter for inspection report |
Inspection Report — May 3, 2016
Date: May 3, 2016
Visit Reason
The inspection was an interim licensing inspection conducted by the Pennsylvania Department of Human Services to assess compliance with 55 Pa.Code Chapter 2600 for Personal Care Homes.
Findings
The inspection found violations related to blocked egress routes and unsecured medications. Plans of correction were submitted and partially implemented to address these issues.
Citations (2)
2600.121(a) - Stairways, hallways, doorways, passageways and egress routes must be unlocked and unobstructed. A grey glider bench was blocking the exit door labeled B, preventing immediate egress in an emergency.
2600.183(g) - Prescription medications, OTC medications, CAM and syringes must be kept in a locked area or container. A bag of unlocked medications was found at the reception desk, including glucosamine, Bayer, Anacin, arthritis pain tablets, and others.
Report Facts
Number of Residents Served: 17
Total Daily Staff: 18
Walking Staff: 14
Number of Current Hospice Residents: 1
Inspection Report — Mar 3, 2016
Renewal
Date: Mar 3, 2016
Visit Reason
The inspection was a renewal licensing inspection conducted by the Pennsylvania Department of Human Services for Heartland Retirement Personal Care Home.
Findings
The inspection identified multiple violations related to posting of licensing summaries, emergency phone numbers, soap dispensers, food storage, emergency water supply, medication administration, and medication record keeping. Plans of correction were submitted and partially or fully implemented for all violations.
Citations (11)
55 Pa.Code §2600.3(c) - The home did not post the Licensing Inspection Summaries for 7/22/15, 9/11/15, or 10/15/15.
55 Pa.Code §2600.91 - Resident room #9 did not have required emergency numbers posted by the phone for police, fire, EMS, poison control, and complaint hotline.
55 Pa.Code §2600.102(i) - A soap dispenser was not available in the back bathroom closest to the lounge.
55 Pa.Code §2600.103(d) - Food was stored directly on the floor in the main freezer, including a 10 lbs. box of roast beef.
55 Pa.Code §2600.107(c) - The home was required to have 48 gallons of emergency water but only had 40 gallons on hand and lacked a letter from the water supplier.
55 Pa.Code §2600.182(b) - Only 1 of 4 required Medication Administration Record Reviews for staff person A was completed.
55 Pa.Code §2600.183(b) - Resident #1 had OTC eye drops accessible in an unlocked room.
55 Pa.Code §2600.183(d) - Resident #2's inhaler box was not dated to indicate when first opened and discard date was missing.
55 Pa.Code §2600.187(a) - Resident #3's glucometer reading requiring insulin was not recorded on the MAR and insulin was not administered as ordered.
55 Pa.Code §2600.187(d) - The home did not follow the prescriber's directions for Resident #3's medication administration.
55 Pa.Code §2600.251(b) - White out correction fluid was used on staff person A's Medication Administration Review dated 7-7-15.
Report Facts
Number of Residents Served: 16
Total Daily Staff: 19
Waking Staff: 14
Number of Residents Age 60 or Older: 16
Number of Residents with Mobility Need: 3
Gallons of Emergency Water Required: 48
Gallons of Emergency Water on Hand: 40
Required Medication Administration Record Reviews: 4
Completed Medication Administration Record Reviews: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Callahan | Owner/Administrator | Named as legal entity representative and signer of plans of correction |
Notice — July 20, 2023
Date: July 20, 2023
Visit Reason
This document serves as a license renewal notification for Heartland Retirement Personal Care Home and informs that the Department will conduct an onsite inspection within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It confirms issuance of a regular license following the renewal application.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed the renewal notification letter. |
Report — August 28, 2018
August 28, 2018
Report — April 17, 2018
April 17, 2018
Report — March 1, 2018
March 1, 2018
Report — September 19, 2017
September 19, 2017
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