Inspection Reports for
The Hearth at Drexel
238 Belmont Ave, Bala Cynwyd, PA 19004, United States, PA, 19004
Back to Facility Profile36 Reports
Notice — Apr 20, 2026
Date: Apr 20, 2026
Visit Reason
The document serves as a waiver approval for an assisted living administrator to temporarily serve without completing the full required training and orientation prior to employment, under specified conditions.
Findings
The waiver allows the administrator to serve while attending required training courses and orientation by specified dates, with supervision until compliance is met. Documentation must be maintained and made available upon request.
Report Facts
Training hours: 15
Orientation duration: 1
Inspection Report — Jan 15, 2026
Monitoring
Date: Jan 15, 2026
Visit Reason
The visit was a partial, unannounced monitoring inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing to review compliance and verify the submitted plan of correction.
Findings
The inspection found issues with the documentation and calibration of glucometers used for residents. Immediate corrective actions were taken, and a plan of correction was implemented to ensure ongoing compliance through weekly audits supervised by the Director of Nursing.
Citations (1)
185a Storage procedures: The residence failed to properly document glucometer readings and calibrations for residents. Calibration times and readings were inconsistent or missing on the medication administration record.
Report Facts
Residents Served: 75
Special Care Unit Residents Served: 19
Residents Age 60 or Older: 75
Residents with Mobility Need: 43
Total Daily Staff: 118
Waking Staff: 89
Inspection Report — Apr 2, 2025
Follow-Up
Date: Apr 2, 2025
Visit Reason
The visit was a partial, unannounced inspection conducted due to an incident at the facility, followed by review of submitted plans of correction.
Findings
The inspection found deficiencies related to medication storage, labeling, and administration procedures. The facility submitted and implemented plans of correction, including weekly audits and staff education, which were accepted and deemed fully implemented.
Citations (3)
Medication present in the medication cart was past the discard date per manufacturer’s instructions.
An OTC medication bottle in the medication cart was not labeled with the resident’s name or room number.
A medication administration error occurred where a resident was administered medication twice due to staff not reviewing medication records properly.
Report Facts
Residents Served: 74
Special Care Unit Residents Served: 19
Hospice Current Residents: 2
Residents with Mobility Need: 41
Residents Age 60 or Older: 74
Total Daily Staff: 115
Waking Staff: 86
Inspection Report — Mar 6, 2025
Complaint Investigation
Date: Mar 6, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation to review compliance with medication administration and documentation procedures.
Complaint Details
The visit was complaint-related with findings of medication administration errors and documentation issues. The plan of correction was accepted and implemented.
Findings
The inspection found deficiencies related to improper documentation of narcotic medication administration and failure to follow prescriber’s orders for as-needed medications. Corrective actions and weekly audits were implemented to ensure compliance.
Citations (2)
Staff documented all administration on the standing order narcotic sheet instead of the as-needed order sheet.
Medication was administered outside the prescribed as-needed order intervals.
Report Facts
Residents Served: 73
Special Care Unit Residents Served: 20
Hospice Current Residents: 2
Residents Age 60 or Older: 73
Residents with Mobility Need: 43
Total Daily Staff: 116
Waking Staff: 87
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in corrective action and plan of correction related to medication documentation and audits |
| Nurse Manager | Nurse Manager | Responsible for performing weekly audits to maintain compliance |
Inspection Report — Oct 23, 2024
Renewal
Date: Oct 23, 2024
Visit Reason
The inspection was a renewal inspection conducted as a full, unannounced visit on October 23-24, 2024, to assess compliance with licensing requirements and regulations.
Findings
Multiple deficiencies were identified including confidentiality breaches with medication packets, lack of carbon monoxide detectors near gas appliances, privacy violations due to camera recordings, inadequate staff training plans, disability accommodation issues, unlocked poisonous materials, unsanitary conditions, hazards such as cords crossing floors, missing emergency phone numbers, missing window screens, broken furniture, improper refrigerator temperatures, outdated food, obstructed egress, incomplete medical evaluations, unlocked medications, incomplete support plans, and use of non-standardized forms. Plans of correction were submitted with various completion dates, some deficiencies were repeated from prior inspections.
Citations (22)
Medication cellophane packets with resident names were found in trash on medication cart, breaching confidentiality.
Carbon monoxide detectors were not installed within 15 feet of gas appliances in kitchen and basement dryers.
Cameras were recording without signage and captured resident room door, violating privacy.
Staff training plan lacked required details such as names, titles, and training locations.
Bedside mobility device in room #W58 was uncovered and exceeded FDA zone 1 requirements.
Poisonous toothpaste was unlocked and accessible to residents in Special Care Unit.
Unsanitary conditions including dead bugs in dining room light fixtures, spoiled food, malodorous bathrooms, and dirty shower floors.
Power cord crossing floor in room #11 created a hazard.
Emergency telephone numbers for hospital and fire department were missing on phones in rooms #09 and #E64.
Kitchen window lacked a screen.
Bathroom cabinet drawer front panel fell off in room #58.
Refrigerator temperatures exceeded safe limits (50°F and 58°F) in East area refrigerator.
Outdated and unlabeled food items including ice cream, butter, and dressing found in refrigerators and freezer.
Blocked egress with stop sign on patio door on first floor east side.
Medical evaluations for residents #4, #6, and #7 lacked required tuberculosis test/chest x-ray and medication regimen documentation.
Resident #4's annual medical evaluation was not completed within required timeframe.
Prescription sunscreen was unlocked and accessible in room #7.
Resident #5's support plan was not reviewed quarterly as required.
Resident #4's support plan did not address need for bedside mobility device.
Resident #7 participated in support plan development but did not sign the plan.
Correction fluid was used on resident #4's assessment and support plan.
Resident #5 and #7's assessment and support plans were not completed on the Department's standardized form.
Report Facts
Residents Served: 75
Special Care Unit Residents Served: 17
Total Daily Staff: 116
Waking Staff: 87
Residents 60 Years or Older: 66
Residents with Mobility Need: 41
Follow-Up Dates: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named in multiple findings related to medication confidentiality, staff training, disability accommodation, medication storage, medical evaluations, and support plan corrections. | |
| Director of Facilities | Named in findings related to carbon monoxide detectors, privacy camera adjustments, sanitary conditions, hazard corrections, window screens, furniture repairs, and environmental audits. | |
| Director of Dining | Named in findings related to refrigerator temperatures, food safety, outdated food removal, and food labeling. | |
| Administrator | Named in findings related to privacy camera system changes and environmental rounds audit updates. | |
| Nurse Manager | Named in findings related to monitoring poisonous materials and compliance activities. | |
| LPN Charge Nurses | Named in findings related to medication storage and daily inspections. | |
| Nurse Managers | Named in findings related to auditing mobility devices, support plan reviews, and medical record compliance. |
Notice — Feb 13, 2024
Date: Feb 13, 2024
Visit Reason
The document grants a waiver to The Hearth at Drexel facility to use portable space heaters temporarily because the facility's heating system is out of order and being repaired.
Findings
The waiver is granted with specific conditions including use of approved heaters, clearance requirements, hourly fire checks, staff training, daily inspections, and a permit period through March 1, 2024. Noncompliance may result in waiver termination or licensing action.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Inspection Report — Jan 26, 2024
Complaint Investigation
Date: Jan 26, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation with an unannounced partial inspection on 01/26/2024.
Complaint Details
The inspection was complaint-driven, investigating incidents related to resident privacy, medication storage, emergency procedures, and resident access. The submitted plan of correction was fully implemented as of 04/05/2024.
Findings
Multiple deficiencies were found related to resident record confidentiality, privacy violations due to unnotified video devices, unlocked poisonous materials and medications accessible to residents, restricted resident access to living units, failure to follow emergency procedures, incomplete medication records, and improper use of bedside rails. All deficiencies had plans of correction accepted and were implemented by 04/05/2024.
Citations (9)
Resident records were accessible, unattended, and unlocked in the nurse's station with doors open, making records easily accessible.
Voice-controlled video devices were located in resident rooms without notification signs indicating video and audio surveillance.
Unlocked and accessible poisonous materials (toothpaste) were found, and not all residents were assessed capable of safely using or avoiding poisons.
Residents did not have access to their living units at all times; some unit doors were locked preventing access without staff assistance.
The residence did not follow written emergency procedures during a utility emergency; residents were not relocated despite portable heaters being provided.
Written emergency procedures had not been submitted annually to the local emergency management agency.
Prescription medications were unlocked, unattended, and accessible in resident bathrooms; residents were not assessed as capable of self-administering medication.
Medication records were incomplete; prescribed medications present in resident units were not on the medication administration record.
Half-length rails were used on a resident's bed without assessment or support plan addressing the medical symptoms necessitating their use.
Report Facts
Residents Served: 74
Special Care Unit Residents Served: 19
Hospice Residents: 6
Residents 60 Years or Older: 74
Residents with Mobility Need: 34
Total Daily Staff: 108
Waking Staff: 81
Inspection Report — Nov 21, 2023
Complaint Investigation
Date: Nov 21, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation during an unannounced partial inspection on 11/21/2023.
Complaint Details
The inspection was complaint-related and included an incident. The submitted plan of correction was fully implemented as of 02/09/2024.
Findings
The inspection found deficiencies related to annual medical evaluations, annual resident assessments, and support plan signatures. The facility submitted a plan of correction which was accepted and fully implemented by 02/09/2024.
Citations (3)
Resident medical evaluations were not completed annually as required.
Resident assessments were not completed annually as required.
Residents participated in support plan development but did not sign and date the support plan.
Report Facts
Residents Served: 72
Special Care Unit Residents Served: 19
Current Hospice Residents: 1
Total Daily Staff: 92
Waking Staff: 69
Inspection Report — Oct 11, 2023
Renewal
Date: Oct 11, 2023
Visit Reason
The inspection was conducted as a renewal review of THE HEARTH AT DREXEL facility on 10/11/2023 and 10/12/2023 to determine compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including failure to post current violation reports, incomplete abuse reporting, untimely incident reporting, inadequate staff training in fire safety and dementia care, medication management issues, sanitary and safety concerns, and incomplete resident records. Plans of correction were accepted and implemented by 02/28/2024.
Citations (33)
Failure to post current violation reports in a conspicuous and public place.
Allegation of resident abuse was not reported to the local Area Agency on Aging.
Incidents including falls, medication errors, and hospitalizations were not reported to the Department within required timeframes.
Resident records left unlocked and unattended in medication room.
Insufficient posting of 'No Smoking' signs at all entrances and designated areas.
Inadequate food safety certification coverage during kitchen hours.
Staff did not receive required orientation and annual training in fire safety, emergency preparedness, resident rights, abuse reporting, and dementia care.
Poisonous materials were unlocked and accessible to residents in memory care bedrooms.
Sanitary conditions not maintained in kitchen refrigerators and freezers.
Bathroom exhaust fans not working in multiple rooms.
Resident did not have access to operable bedside lamp.
Refrigerator and freezer temperatures exceeded required limits.
Outdated or unlabeled food items found in refrigerators and freezers.
Annual fire safety inspection and fire drill not conducted timely; fire drill records incomplete.
Residence exceeded maximum safe evacuation time; no written maximum evacuation time specified.
Residents' medical evaluations and assessments not completed timely or documented.
Smoking occurred outside designated areas on facility grounds.
Menus not posted in a conspicuous and public place or were outdated.
Medications and syringes were unlocked and accessible in memory care unit.
Discontinued medications remained in medication carts.
Medication administration orders lacked specific administration times.
Medication storage procedures not followed; medication unavailable when needed.
Medication administration training records incomplete or inaccurate.
Weekly activity calendar not posted in a conspicuous and public place.
Preliminary support plans not completed within 30 days prior to admission.
Annual resident assessments and support plans not completed timely.
Resident did not sign support plan despite participation in development.
Residents in special care unit not assessed quarterly for continuing need.
Special care unit outdoor patio gate lacked electronic or magnetic locking system.
Initial support plan for special care unit admission not completed within 72 hours.
Direct care staff in special care unit did not receive required initial and annual dementia training hours.
Direct care staff in special care unit did not complete required dementia training topics.
Resident records missing required demographic information such as race, hair color, or eye color.
Report Facts
Residents Served: 66
Memory Care Residents Served: 17
Staff Total Daily: 99
Staff Waking: 74
Medication Training Hours: 11
Freezer Temperature: 10
Freezer Temperature: 12
Fire Safety Inspection Date: 2022
Fire Drill Evacuation Time: 150
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Direct care staff person | Named in findings related to incomplete dementia training and initial orientation. |
| Staff person B | Direct care staff person | Named in findings related to incomplete dementia training and initial orientation. |
| Staff person C | Direct care staff person | Named in findings related to incomplete dementia training and initial orientation. |
| Staff person D | Direct care staff person | Named in findings related to incomplete annual training and dementia training. |
| Staff person E | Direct care staff person | Named in findings related to incomplete annual fire safety training. |
| Staff person F | Direct care staff person | Named in findings related to incomplete medication administration training. |
| Director of Nursing | Director of Nursing | Responsible for reporting abuse, medication order accuracy, staff training, and resident record compliance. |
| Director of Dining Services | Director of Dining Services | Responsible for food safety certification, refrigerator/freezer temperature monitoring, and menu posting. |
| Director of Facilities | Director of Facilities | Responsible for posting no smoking signs, fire safety training, and maintenance of exhaust fans. |
Inspection Report — Jul 6, 2023
Complaint Investigation
Date: Jul 6, 2023
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial review to assess compliance and verify the submitted plan of correction.
Complaint Details
The inspection was complaint-driven, focusing on the facility's response to a hot water outage incident and related emergency procedures. The submitted plan of correction was accepted and fully implemented.
Findings
The facility was found to have violated requirements related to incident reporting, personal hygiene, and emergency procedures due to a hot water outage lasting four days, which impacted residents' ability to maintain hygiene and the failure to follow emergency evacuation procedures. The submitted plan of correction was fully implemented and compliance was maintained.
Citations (3)
Failure to report the hot water outage incident to the Department within 24 hours as required.
Residents did not receive showers and basic hygiene during the hot water outage period.
The home did not follow written emergency procedures and failed to evacuate residents during the utility emergency, allowing residents to go without hot water.
Report Facts
Residents Served: 69
Special Care Unit Residents Served: 14
Current Hospice Residents: 6
Residents with Mobility Need: 20
Residents 60 Years or Older: 69
Inspection Report — Dec 9, 2022
Complaint Investigation
Date: Dec 9, 2022
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on 12/09/2022, 12/13/2022, and 12/22/2022.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were substantiated.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 70
Secured Dementia Care Unit Residents Served: 15
Hospice Current Residents: 7
Residents Age 60 or Older: 71
Residents with Mobility Need: 33
Inspection Report — Jul 18, 2022
Renewal
Date: Jul 18, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the facility license.
Findings
The inspection found sanitary condition deficiencies related to a urine-containing item observed on a resident's nightstand. The facility submitted an acceptable plan of correction to address the issue.
Citations (1)
Sanitary conditions were not maintained as a urine-containing item was observed on a resident's nightstand.
Report Facts
Residents Served: 71
Special Care Unit Residents Served: 15
Hospice Residents: 7
Residents 60 Years or Older: 71
Residents with Mobility Need: 33
Total Daily Staff: 104
Waking Staff: 78
Inspection Report — Jan 19, 2022
Date: Jan 19, 2022
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, on 01/19/2022.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 66
Special Care Unit Residents Served: 13
Hospice Residents: 2
Resident Support Staff: 0
Total Daily Staff: 94
Waking Staff: 71
Residents Age 60 or Older: 66
Residents with Mobility Need: 28
Inspection Report — Jun 4, 2021
Date: Jun 4, 2021
Visit Reason
The inspection was a partial, unannounced licensing inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 06/04/2021, related to an incident.
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
Residents with Mobility Need: 24
Residents Age 60 or Older: 63
Resident Support Staff: 0
Total Daily Staff: 87
Waking Staff: 65
Inspection Report — May 27, 2021
Renewal
Date: May 27, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 05/27/2021 and 05/28/2021.
Findings
The inspection found multiple deficiencies including lack of operable bedside lamps for residents, unlabeled and undated leftover food in kitchenettes, obstructed egress routes, presence of medications not listed on physician orders, and incomplete resident records missing recent photographs. Plans of correction were accepted and implemented with education and audits scheduled to ensure ongoing compliance.
Citations (5)
Residents #1 and #2 did not have access to a source of light that can be turned on/off at bedside.
Unlabeled and undated leftover food items found in kitchenettes and refrigerators.
A 'do not enter' sign and mesh banner blocked egress from the second floor west wing rear fire exit.
Medications (Nitroglycerin, Metoprolol ER, Zinc) present in the home for residents #3 and #4 were not listed on physician's orders.
Resident #1's record did not include a photograph less than 2 years old.
Report Facts
Residents Served: 63
Special Care Unit Residents Served: 13
Residents with Mobility Need: 24
Residents Age 60 or Older: 63
Total Daily Staff: 87
Waking Staff: 65
Notice — Apr 6, 2021
Date: Apr 6, 2021
Visit Reason
The document serves as a renewal notification and license issuance for The Hearth at Drexel Assisted Living 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 is an administrative notice confirming license renewal and outlining future inspection requirements.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
Inspection Report — Dec 10, 2020
Complaint Investigation
Date: Dec 10, 2020
Visit Reason
The inspection was a partial, unannounced visit triggered by an incident, conducted over three days to investigate compliance and licensing issues at The Hearth at Drexel.
Complaint Details
The inspection was conducted due to an incident, as indicated by the reason for inspection being 'Incident'.
Findings
The inspection identified a citation related to the revision of a resident's final support plan, which was not updated within the required 30-day period following the annual assessment. The facility submitted an acceptable plan of correction to address this deficiency.
Citations (1)
227c Final support plan - revision. Resident #1’s support plan was not revised within 30 days after the annual assessment completed on 10/26/20, being updated only on 12/08/20.
Report Facts
Residents Served: 65
Memory Care Residents Served: 15
Hospice Current Residents: 5
Total Daily Staff: 106
Waking Staff: 80
Residents 60 Years or Older: 65
Residents with Mobility Need: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dean Gray | Lead Inspector | Lead inspector for the partial inspection conducted on 12/10/2020 |
| Mia Johnson | Lead Reviewer | Reviewer for the plan of correction submission on 1/6/2021 |
| Paulita Moore-Hall | Director of Nursing | Named in relation to the plan of correction and policy review |
Inspection Report — Dec 10, 2020
Follow-Up
Date: Dec 10, 2020
Visit Reason
The inspection was conducted as a follow-up to verify the implementation of a previously submitted plan of correction related to resident support plans.
Findings
The submitted plan of correction was found to be fully implemented with all final support plans audited and in compliance. Continued compliance must be maintained.
Citations (1)
227c Final support plan - revision: Resident #1’s assessment was completed on 10/26/20; however, the resident’s support plan was not revised until 12/08/20.
Report Facts
Residents Served: 65
Special Care Unit Residents Served: 15
Hospice Current Residents: 5
Residents Age 60 or Older: 65
Residents with Mobility Need: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mia Johnson | Signed letter confirming plan of correction implementation | |
| Director of Nursing | Named in plan of correction review and policy adherence |
Inspection Report — Oct 28, 2020
Complaint Investigation
Date: Oct 28, 2020
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial licensing inspections on 10/28/2020, 10/29/2020, 11/02/2020, and 11/03/2020.
Complaint Details
The inspection was complaint-related and the exit conference was held on 11/04/2020. No deficiencies or citations were found, indicating no substantiated violations.
Findings
No regulatory citations or deficiencies were identified as a result of this complaint investigation inspection.
Report Facts
Residents Served: 67
Special Care Unit Residents Served: 16
Resident Support Staff Total Daily Staff: 109
Waking Staff: 82
Residents with Mobility Need: 42
Residents 60 Years or Older: 67
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Youn Hie Chung | Lead Inspector | Lead inspector for the complaint investigation |
Inspection Report — Sep 8, 2020
Follow-Up
Date: Sep 8, 2020
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the submitted plan of correction related to abuse/neglect and staff training deficiencies. The report details the termination of an employee for abuse and deficiencies in required annual and dementia-specific training for direct care staff.
Citations (5)
42b Abuse/Neglect: Staff person B was observed physically abusing resident #1 by grabbing the resident's neck and slapping resident #2's hand. The employee was terminated following investigation.
65h 16 hrs annual training: Direct care staff person B only completed 2 hours of annual training during 2019, below the required 16 hours.
65i Training topics: Direct care staff person B did not complete required training in medication self-administration, dementia care, infection control, safe management, or care for residents with mental illness during 2019.
65j Annual training content: Direct care staff person B did not receive training in fire safety, emergency preparedness, resident rights, the Older Adult Protective Services Act, or falls and accident prevention during 2019.
69 Dementia training: The facility did not provide documentation that direct care staff person B received the required 2 hours of dementia-specific training during 2019.
Report Facts
Residents Served: 82
Special Care Unit Residents Served: 20
Hospice Residents: 4
Staffing Hours - Total Daily Staff: 125
Staffing Hours - Waking Staff: 94
Staffing Hours - Resident Support Staff: 0
Direct Care Staff Person B Annual Training Hours: 2
Dementia-Specific Training Hours Required: 2
Inspection Report — Feb 20, 2020
Renewal
Date: Feb 20, 2020
Visit Reason
The inspection was a full, unannounced renewal inspection conducted on February 20 and 21, 2020 to review compliance with licensing regulations.
Findings
The report documents multiple deficiencies related to incident reporting, staff training, medication management, safety procedures, and resident record keeping. Plans of correction were submitted and approved with full implementation confirmed.
Citations (18)
2800.16c Incident reporting was delayed for multiple residents with falls and injuries resulting in hospitalization or death.
2800.64c The Administrator was unable to verify completion of 24 hours of annual training in 2019.
2800.65e The home failed to provide documentation of core competency training including nutritional support for staff person B.
2800.65h Direct care staff did not complete the required 16 hours of annual training during 2019.
2800.65i Direct care staff did not receive training on medication self-administration, resident needs, infection control, or assisted living service needs during 2019.
2800.65j Direct care staff did not receive fire safety training by a fire safety expert during 2019.
2800.69 Direct care staff did not receive 2 hours of dementia-specific training during 2019.
2800.82c Poisonous materials were unlocked and accessible to resident #10 on the secured dementia unit.
2800.101j Resident #14 did not have access to an operable lamp or source of light at bedside.
2800.103i Multiple food items in the kitchen and food storage were unlabeled and undated.
2800.105g Lint was observed in the dryer lint trap in the laundry room, posing a fire hazard.
2800.107d The home's written emergency procedures had not been reviewed or updated since 2014.
2800.183b Medication and syringes were found unlocked in resident #13's apartment.
2800.183d Medication for resident #11 was discontinued but still present; prescription labels were outdated.
2800.185a Medication prescribed for resident #11 was not available in the residence as required.
2800.187d Resident #9 and #10 did not receive prescribed Ensure nutritional supplements as ordered; resident #11 was not administered Synthroid as prescribed.
2800.234a.1 Support plans were not completed within 72 hours of admission for residents #5 and #10 to the special care unit.
2800.252 Resident records for #7 and #8 did not include required reportable incident documentation.
Report Facts
Residents Served: 82
Special Care Unit Residents Served: 20
Hospice Current Residents: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dana O'Donnell | Executive Director | Named as Administrator and signer of plans of correction. |
Inspection Report — Dec 23, 2019
Complaint Investigation
Date: Dec 23, 2019
Visit Reason
The inspection was conducted as a complaint investigation due to an incident involving staff forcing a resident to drink water.
Complaint Details
The complaint involved an incident where staff person A forced resident #1 to drink water. The incident was investigated and found not to be abuse. The plan of correction was fully implemented.
Findings
The investigation found that the incident was not abuse, but staff failed to submit a required supervision plan to the Department. Additionally, staff did not use positive interventions or understand non-verbal cues during the incident.
Citations (2)
15c Supervision plan submission: Staff forced a resident to drink water and the residence failed to submit a required plan of supervision to the Department.
201 Positive interventions: Staff did not cue or encourage the resident properly and failed to use positive intervention techniques within reasonable time frames.
Report Facts
Residents Served: 81
Special Care Unit Residents Served: 18
Current Hospice Residents: 6
Residents Age 60 or Older: 81
Residents with Mobility Need: 31
Residents with Physical Disability: 1
Notice — Nov 4, 2019
Date: Nov 4, 2019
Visit Reason
The document is a response to a request for a waiver of Pennsylvania Code Chapter 2800 relating to space heaters in an assisted living residence.
Findings
The Department approved the waiver with specific conditions including use of approved heaters, fire watch procedures, clearance requirements, staff training, and inspection protocols. The waiver is effective until April 29, 2020, contingent on compliance with these conditions.
Report Facts
Waiver expiration date: Apr 29, 2020
Heater wattage: 1500
Fire watch interval: 1
Fire watch coverage: 24
Clearance distance: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeanne Parisi | Director | Signed the waiver approval letter. |
Document — Apr 12, 2019
Date: Apr 12, 2019
Visit Reason
The document is a regulatory approval letter from the Pennsylvania Department of Human Services approving The Hearth at Drexel to admit a resident with an excludable condition involving two healing stage III pressure ulcers, submitted as a Request to Admit a Resident with an Excludable Condition (RAREC).
Findings
The Department reviewed submitted documentation and determined the resident can be safely served in the licensed setting with licensed nursing staff present 24 hours per day to provide appropriate wound care. The approval is contingent on notifying the Department if the ulcers worsen or become purulent, odorous, or expand in size.
Report Facts
Healing Stage III pressure ulcers: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dana O'Donnell | Administrator/Executive Director | Named as the administrator submitting the RAREC request and signing related documents. |
| Brian Shovlin | Family member supporting the waiver request for resident admission. | |
| Antamarie Daley | Executive Director Liberty at Home, Liberty Hospice | Signed letter supporting supplemental home health care services for the resident. |
| Jacqueline L. Rowe | Director | Signed the Department of Human Services approval letter. |
Notice — Mar 28, 2019
Date: Mar 28, 2019
Visit Reason
This document serves as a renewal notification and certificate of compliance for The Hearth at Drexel Assisted Living Home, confirming the facility's licensed capacity and informing about 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 and outlines the Department's obligation to conduct an annual inspection.
Report Facts
Inspection Report — Feb 13, 2019
Renewal
Date: Feb 13, 2019
Visit Reason
The inspection was a renewal licensing inspection conducted on February 13 and 14, 2019, for The Hearth at Drexel assisted living residence.
Findings
Multiple violations were found related to resident contracts, resident rights, privacy, staff background checks, training, storage of poisonous materials, hot water temperatures, food storage, medical evaluations, medication administration, and support plans. Plans of correction were submitted and partially implemented as of April 22, 2019.
Citations (19)
Resident #1 admitted on 06/21/2018 did not sign his contract as required by regulation 2800.25(b).
Resident #1 did not sign the Resident Rights and Complaint Procedures as required by regulation 2800.41(e).
Video camera #33 in the 1st floor living room area could see into the foyer of room E21, violating resident privacy under regulation 2800.42(s).
The criminal background check for Staff A, hired on 01/14/2019, was not requested until 01/22/2019, violating regulation 2800.52.
Direct care staff person B, hired on 11/13/2018, did not have at least 4 hours of dementia-specific training within 30 days of hire as required by regulation 2800.69.
The beauty parlor in the secured dementia care unit had drawers full of poisonous hair products unlocked, violating regulation 2800.82(c).
Hot water temperatures in resident rooms E65, W58, and W17 exceeded 120°F on 02/14/2019, violating regulation 2800.89(b).
Freezers in the East and West Wing kitchen areas did not have thermometers as required by regulation 2800.103(f).
Certificates for the home's cast iron hot water heating boilers expired on 02/06/2019, violating regulation 2800.128(a).
The medical evaluation for resident #2 dated 01/25/2019 did not include an indication of a tuberculin skin test as required by regulation 2800.141(a).
Resident #2's most recent medical evaluation was dated 01/25/2019, while the previous one was dated 10/02/2017, violating the annual evaluation requirement of regulation 2800.141(b)(1).
The glucometer for resident #4 was not calibrated to the correct date and time, violating regulation 2800.185(a).
Resident #5's Milk of Magnesia and Tylenol 325 mg PRN medications were not in the home, violating regulation 2800.185(a).
Resident #1 was not educated on the right to question or refuse medication as required by regulation 2800.191.
The home did not have Latanoprost 0.005% eye drops for resident #1, Senokot 8.6 mg for resident #4, and Tylenol 500 mg and Senna 8.6 mg for resident #5 as required by regulation 2800.187(d).
The most recent ASP for resident #2 was dated 01/04/2018, and the most recent ASP for resident #6 was dated 02/12/2019, violating regulation 2800.226(a).
Resident #6's ASP was not signed by the resident as required by regulation 2800.227(b).
Resident #8 was admitted to the home's secured dementia care unit on 07/02/2018 without a completed cognitive preadmission screening form, violating regulation 2800.231(e)(1).
Resident #7 was admitted to the home's secured dementia care unit on 07/03/2017 and was not assessed quarterly for continuing need, violating regulation 2800.231(e)(1).
Report Facts
Number of Residents Served: 76
Number of Residents Served in Secured Dementia Care Unit: 17
Number of Current Hospice Residents: 2
Number of Hospice Residents in Past Year: 13
Residents 60 Years or Older: 76
Residents with Mobility Need: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dana O'Donnell | Executive Director/Administrator | Named as legal entity representative and signer of plans of correction |
Inspection Report — Oct 18, 2018
Routine
Date: Oct 18, 2018
Visit Reason
The Department’s Bureau of Human Services Licensing conducted an inspection of the facility to assess compliance with 55 Pa. Code Chapter 2800 relating to Assisted Living Residence.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Notice — Apr 16, 2018
Date: Apr 16, 2018
Visit Reason
This document serves as a renewal notification and license issuance for The Hearth at Drexel Assisted Living Home following receipt of the renewal application dated March 16, 2018.
Findings
No inspection findings are reported. The letter states that an onsite annual inspection will be conducted within the next twelve months as required by regulation.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joan M. Myers | Interim Administrator/Executive Director | Recipient of the renewal notification letter |
| Jacqueline L. Rowe | Director | Signed the renewal notification letter |
Inspection Report — Mar 19, 2018
Renewal
Date: Mar 19, 2018
Visit Reason
The inspection was a full renewal inspection conducted on March 19, 2018, to assess compliance with 55 Pa.Code Chapter 2800 for The Hearth at Drexel assisted living residence.
Findings
The inspection identified multiple violations related to resident safety, medication administration, and behavior management. Plans of correction were submitted addressing physical assault between residents, medication administration errors, and inadequate positive behavioral interventions.
Citations (4)
Regulation 42(b): Resident #1 physically assaulted Resident #2, with prior history of combative behavior. Resident #1 was removed and interventions provided.
Regulation 187(d): Resident #1 was prescribed Clonazepam and Amlodipine, but medication administration records were incomplete and medications were not administered as ordered.
Regulation 201: Resident #1 exhibited aggressive and combative behaviors without use of positive behavioral strategies. Medication was used without prior positive interventions.
Regulation 227(c): Resident #1's support plan was not updated to reflect aggressive and combative behaviors exhibited after admission. Support plans lacked necessary revisions.
Report Facts
Number of Residents Served: 68
Number of Residents Served in Secured Dementia Care Unit: 18
Number of Current Hospice Residents: 5
Number of Hospice Residents in Past Year: 19
Residents Age 60 or Older: 68
Residents with Mental Illness: 3
Residents with Mobility Need: 24
Residents with Physical Disability: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dana O'Donnell | Administrator | Signed plans of correction related to multiple violations |
Notice — Feb 22, 2018
Date: Feb 22, 2018
Visit Reason
This document is a waiver approval letter granting an exception to administrator training and orientation requirements for an employee at The Hearth at Drexel.
Findings
The waiver is granted under specific conditions including completion of orientation, training courses, and submission of certificates. The waiver will expire on June 15, 2018, after which full compliance is expected.
Report Facts
Waiver expiration date: Jun 15, 2018
License number: 140620
Inspection Report — Jun 29, 2017
Renewal
Date: Jun 29, 2017
Visit Reason
The inspection was a full renewal licensing inspection conducted on June 29, 2017, for The Hearth at Drexel assisted living residence.
Findings
Multiple violations were found related to emergency procedures, fire safety documentation, lighting in resident rooms, medical evaluations, medication administration, and support plan documentation. Plans of correction were submitted addressing each violation with partial implementation noted.
Citations (10)
Regulation 107(d): The home failed to provide written emergency procedures submitted annually to the local emergency management agency.
Regulation 132(d): The fire safety inspection report did not include documentation that the home can evacuate to a public thoroughfare or designated fire-safe area.
Regulation 101(1)(7): Bedroom 11 did not have a source of light that could be turned on or off from the bedside.
Regulation 141(a)(11): Resident #1's record lacked documentation of a tuberculin skin test within required timeframes.
Regulation 183(d): Discontinued medication (Oxycodone/APAP) was still present on the medication cart for resident #2 at time of inspection.
Regulation 185(a): The home failed to document medication administration properly, with blank spaces and missing signatures for residents #2, #3, and #4.
Regulation 187(b): The home failed to document the date, time, and staff administering resident #3's Lorazepam medication on 6/19/17.
Regulation 187(d): Resident #4 did not receive prescribed Zolpidem medication from June 15-22, 2017, and the home failed to document the refusal or delivery status.
Regulation 190(c): The home failed to provide documentation of medication administration training for staff person A for 2016.
Regulation 227(h): Resident #1 initially refused to sign the support plan, and the home failed to document whether the resident was unable or chose not to sign.
Report Facts
Number of Residents Served: 61
Number of Residents Served in Secured Dementia Care Unit: 16
Number of Current Hospice Residents: 3
Number of Hospice Residents in Past Year: 14
Residents 60 Years or Older: 60
Residents with Mobility Need: 27
Inspection Report — Mar 28, 2017
Renewal
Date: Mar 28, 2017
Visit Reason
The document is a renewal application and license issuance for The Hearth at Drexel Assisted Living Home. The Department of Human Services will conduct an onsite inspection within the next twelve months as required by state regulations.
Findings
This document does not contain inspection findings but confirms the renewal of the facility's license to operate an assisted living home with a maximum capacity of 85 residents.
Report Facts
Inspection Report — Jun 7, 2016
Renewal
Date: Jun 7, 2016
Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing renewal inspections on June 7 and 8, 2016 for The Hearth at Drexel assisted living residence.
Findings
Violations of 55 Pa.Code Chapter 2800 related to resident neglect and failure to involve designated persons in support plan development were found. Plans of correction were submitted addressing abuse reporting and family involvement in support plans.
Citations (2)
Regulation 42b: A resident admitted to the special care unit was physically abused by a staff member resulting in a laceration to the resident's nose.
Regulation 234e: The designated person or family of a resident was not involved in the development and revisions of the resident's support plans dated 4/29/16 and 5/31/16.
Report Facts
Number of Residents Served: 40
Number of Residents Served in Secured Dementia Care Unit: 13
Number of Current Hospice Residents: 4
Number of Hospice Residents in Past Year: 8
Number of Residents 60 Years or Older: 40
Number of Residents with Mobility Need: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Betty Bebian | RN, NHA Administrator | Signed plans of correction and is the facility administrator |
Inspection Report — Apr 12, 2016
Renewal
Date: Apr 12, 2016
Visit Reason
The document is a renewal of the license to operate The Hearth at Drexel Assisted Living Home. The Department of Human Services will conduct an onsite inspection within the next twelve months as part of the annual inspection requirement.
Findings
The document does not report any inspection findings but confirms the issuance of a regular license following the renewal application and outlines the requirement for a future inspection within twelve months.
Report Facts
Notice — April 7, 2020
Date: April 7, 2020
Visit Reason
This document serves as a license renewal approval for The Hearth at Drexel Assisted Living Home and notifies that an onsite annual 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 issuance of a regular license following the renewal application.
Report — October 15, 2020
October 15, 2020
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