Inspection Reports for Heartful Hands LLC
514 MITCHELL AVENUE,, CLARITON, PA, 15025
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
31.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
566% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
28
21
14
7
0
Census
Latest occupancy rate
81% occupied
Based on a July 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Monitoring
Census: 29
Capacity: 36
Deficiencies: 8
Jul 17, 2025
Visit Reason
The inspection was an unannounced partial monitoring visit conducted on 07/17/2025 and 07/18/2025 to review compliance with regulatory requirements and verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have multiple deficiencies including lack of criminal background checks for staff, inadequate medication administration staffing, incomplete staff orientation and training, improperly stored fire extinguisher, incomplete fire drill records, and medication record errors. The submitted plan of correction was accepted and fully implemented by 09/03/2025.
Deficiencies (8)
| Description |
|---|
| Staff person A did not have a criminal history background check completed. |
| No qualified staff person to administer medications on the 11:00 p.m.-7:00 a.m. shift. |
| Staff person A did not receive orientation in required fire safety and emergency preparedness topics on the first day of work. |
| Staff person A did not receive orientation training within 40 scheduled working hours as required. |
| An unlocked, improperly stored fire extinguisher was accessible to residents, causing a safety hazard. |
| Fire drill record did not include the amount of time to evacuate. |
| Resident's medication administration record did not include a prescribed medication for pain or fever. |
| Resident did not receive prescribed insulin dose despite blood glucose reading indicating need. |
Report Facts
License Capacity: 36
Residents Served: 29
Total Daily Staff: 30
Waking Staff: 23
Deficiencies cited: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelley Martin | Conducts file audits for staff compliance | |
| Nyhemia | Reviews medication administration records and medication cart three times per week | |
| Shannon | Reviews medication administration records and medication cart three times per week | |
| JU | Staff trained explicitly on medication administration |
Inspection Report
Renewal
Census: 27
Capacity: 36
Deficiencies: 27
Apr 21, 2025
Visit Reason
The inspection was a full, unannounced renewal survey conducted to assess compliance with regulations and licensing requirements for Heartful Hands LLC.
Findings
The inspection identified multiple deficiencies including failure to post current licensing inspection summaries, delayed incident reporting, incomplete resident contracts and assessments, inadequate staff training and orientation, medication administration issues, fire safety violations, and deficiencies in resident records and support plans.
Deficiencies (27)
| Description |
|---|
| Licensing inspection summaries dated 7/8/23, 10/20/23 and 8/20/24 were not posted in a conspicuous and public place. |
| Incident of resident #1 smacking resident #2 was not reported to the Department until nearly a month later. |
| Resident #10 did not have a completed resident-home contract. |
| Multiple staff persons lacked completed criminal background checks. |
| Administrator was present only 11 hours per week, less than the required 20 hours. |
| No qualified staff person to administer medications overnight from 4/1/25 to 4/21/25. |
| Staff list did not include all current employees' contact information. |
| Administrator had not completed required 100-hour training and competency test. |
| Staff persons C and E lacked required fire safety orientation training. |
| Staff persons F and G lacked required orientation and annual training hours, including emergency preparedness and care for residents with mental illness. |
| No annual staff training plan developed for 2025. |
| Exit door from bathroom #3 did not fully close, leaving a 3-inch gap. |
| Fire drill records incomplete or inaccurate, including unclear times and missing details. |
| Residents did not fully evacuate during fire drills; one resident refused to go during a drill. |
| Fire drills used only one exit route repeatedly instead of alternating exits. |
| Resident #8 prescribed Mounjaro injectable medication administered by uncertified staff. |
| Resident #9's prescribed Diphenhydramine medication was not available in the home. |
| Resident #2's Hydrocortisone cream was administered but not documented on the medication administration record (MAR). |
| Staff person F did not initial the MAR after administering medication to resident #8. |
| Staff persons F and G had not completed required diabetes patient education within the past 12 months but administered insulin. |
| Resident #2 and #10 did not have completed preadmission screening forms prior to admission. |
| Resident #2 and #10 did not have written initial assessments completed within 15 days of admission. |
| Residents #5, #6, and #10 did not have annual additional assessments completed timely. |
| Resident #2 and #10 did not have complete resident records. |
| Resident #2 and #1 did not have annual medical evaluations completed timely. |
| Resident #1 and #2 did not have annual additional assessments completed timely. |
| Resident #2 did not have a written support plan completed within 30 days of admission. |
Report Facts
License Capacity: 36
Residents Served: 27
Staffing Hours: 11
Deficiency Count: 27
Inspection Report
Renewal
Census: 26
Capacity: 36
Deficiencies: 28
Mar 13, 2025
Visit Reason
The inspection was conducted as a complaint investigation with multiple follow-up visits and a renewal inspection to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
The facility was found to have multiple violations including sanitary conditions, staff training deficiencies, incomplete resident assessments, medication administration issues, fire safety violations, and record-keeping deficiencies. Several plans of correction were submitted with some implemented and others pending.
Complaint Details
The complaint investigation was triggered by an incident where resident #1 smacked resident #2 in the face on 3/23/25, which was not reported to the Department until 4/22/25.
Deficiencies (28)
| Description |
|---|
| Brownish, sticky substance on plastic container and residue on dining room floor; power strip and extension cords covered in grime and dust. |
| Latch did not catch on resident's bedroom door; buildup of dirt and grime on floors, baseboards, and furniture; foul odor under floor mat. |
| Bottom drawer of metal filing cabinet rusted and unusable; used for resident personal belongings. |
| Resident medical evaluations and assessments not current or missing for multiple residents. |
| Resident support plans inaccessible to direct care staff and not updated. |
| Licensing inspection summaries not posted in a conspicuous place. |
| Incident of resident smacking another resident not reported to Department within required timeframe. |
| Resident mail not delivered to residents; mail opened by administrator without resident consent. |
| Staff persons without completed criminal background checks employed. |
| Administrator present less than required 20 hours per week. |
| No qualified staff person to administer medications on overnight shift; multiple residents prescribed PRN medications. |
| Staff list incomplete; missing staff contact information. |
| Administrator has not completed Department-approved competency-based training test. |
| Staff persons without required orientation training in fire safety, resident rights, abuse reporting, and job-specific functions. |
| Staff persons without required annual training hours and training topics including emergency preparedness and care for residents with mental illness. |
| No annual staff training plan developed for calendar year 2025. |
| Exit door from bathroom #3 did not fully close; gap of approximately 3 inches. |
| Fire drills not conducted monthly; incomplete or inaccurate fire drill records; failure to evacuate all residents during drills; only one exit route used during drills. |
| Resident medical evaluations and assessments not current or missing for multiple residents. |
| Resident #8 prescribed Mounjaro injectable medication administered by uncertified staff. |
| Resident #9 prescribed Diphenhydramine not available in the home. |
| Resident #2 prescribed Hydrocortisone cream administered but not documented on medication administration record. |
| Resident #8 medication administration not initialed on MAR by staff. |
| Staff persons F and G administered insulin without completing required diabetes patient education within past 12 months. |
| Preadmission screening forms not completed for residents #2 and #10. |
| Written initial assessments not completed for residents #2 and #10 within 15 days of admission. |
| No record kept for residents #2 and #10. |
| Resident #2 does not have a written support plan completed within 30 days of admission. |
Report Facts
Inspection dates: 7
License capacity: 36
Residents served: 26
Staffing hours: 27
Total daily staff: 55
Waking staff: 41
Residents served: 27
Residents served: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person C | Mentioned in relation to lack of criminal background check, lack of orientation training, and incomplete direct care training. | |
| Staff person D | Mentioned in relation to lack of orientation training and incomplete direct care training. | |
| Staff person E | Mentioned in relation to lack of criminal background check, lack of orientation training, lack of ancillary staff orientation, and incomplete training. | |
| Staff person F | Mentioned in relation to incomplete annual training, medication administration documentation, and diabetes training. | |
| Staff person G | Mentioned in relation to incomplete annual training, medication administration, and diabetes training. | |
| Administrator | Administrator | Mentioned in relation to staffing hours, training deficiencies, and oversight of compliance with regulations. |
Inspection Report
Renewal
Census: 26
Capacity: 36
Deficiencies: 20
Mar 13, 2025
Visit Reason
The inspection was conducted as a complaint investigation with multiple visits between March and July 2025, followed by a renewal inspection in April 2025 and a partial incident-related inspection in June 2025.
Findings
The facility was found to have multiple deficiencies including sanitary conditions, staff training and qualifications, medication administration issues, incomplete resident records and assessments, fire safety violations, and failure to post required documents. Several plans of correction were submitted but many were not implemented by the follow-up dates.
Complaint Details
The complaint investigation was triggered by multiple issues including sanitary conditions, staff qualifications, medication administration, and resident care concerns. The investigation included unannounced visits on March 13, 20, and 31, 2025, with an exit conference on March 31, 2025.
Deficiencies (20)
| Description |
|---|
| Brownish, sticky substance and grime on container and floor; power strips and extension cords covered in grime and dust. |
| Latch on resident's bedroom door did not catch; buildup of dirt and grime on floors, baseboards, and furniture. |
| Bottom drawer of metal filing cabinet rusted and unusable. |
| Resident medical evaluations and assessments not current or missing. |
| Resident support plans inaccessible and not updated. |
| Licensing inspection summaries not posted in a conspicuous place. |
| Incident of resident altercation not reported timely to Department. |
| Staff persons without completed criminal background checks employed. |
| Administrator present less than required 20 hours per week. |
| No qualified staff to administer medications overnight shift. |
| Staff list incomplete, missing contact information. |
| Administrator has not completed required training. |
| Staff persons without required orientation and annual training. |
| Emergency procedures not posted; fire drills not conducted monthly or during sleeping hours; fire drill records incomplete; evacuation procedures not fully followed. |
| Resident prescribed medication (Mounjaro) administered by uncertified staff. |
| Resident medication (Diphenhydramine) not available in home. |
| Medication administration records incomplete or not updated. |
| Staff persons administering insulin injections without current diabetes education. |
| Preadmission screening forms and resident assessments missing or incomplete. |
| Resident records missing or incomplete. |
Report Facts
Inspection dates: 7
License capacity: 36
Residents served: 26
Staffing hours: 20
Staffing hours: 27
Total daily staff: 55
Deficiency counts: 20
Follow-up dates: 7
Inspection Report
Complaint Investigation
Census: 32
Capacity: 36
Deficiencies: 0
Apr 4, 2024
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial inspection on 04/04/2024.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies were found and no follow-up was required.
Report Facts
License Capacity: 36
Residents Served: 32
Total Daily Staff: 33
Waking Staff: 25
Residents Receiving Supplemental Security Income: 32
Residents 60 Years or Older: 21
Residents Diagnosed with Mental Illness: 24
Residents Diagnosed with Intellectual Disability: 4
Residents with Mobility Need: 1
Residents with Physical Disability: 0
Inspection Report
Renewal
Census: 33
Capacity: 36
Deficiencies: 18
Jul 28, 2023
Visit Reason
The inspection was conducted as part of a renewal, complaint, provisional, and incident review process for Heartful Hands LLC, a personal care home.
Findings
The facility was found to have multiple deficiencies including issues with carbon monoxide alarm placement, staff CPR/first aid certification, fire safety orientation, sanitary conditions, lighting, furniture and equipment repair, emergency preparedness, fire drill compliance, and resident record content. All deficiencies had plans of correction accepted and were implemented by November 13, 2023. A follow-up partial inspection on October 20, 2023 found no deficiencies.
Deficiencies (18)
| Description |
|---|
| Carbon monoxide alarms were installed too close to furnaces and batteries were not labeled with installation dates. |
| Staff persons present were not certified in first aid or CPR during certain evening hours. |
| Orientation training documentation for fire safety was not dated for a staff member. |
| Orientation training documentation for resident rights and abuse reporting was not dated for a staff member. |
| Staff person did not receive required resident rights training during the 2022 training year. |
| Unsanitary conditions observed including tobacco on resident's sheets, dusty bathroom fan, soiled incontinence pad on bathroom floor, and grime on banister. |
| Overhead light in bedroom #12 was inoperable. |
| Resident #2's bedside table was damaged exposing sharp staples. |
| Concrete landing at front steps was deteriorated presenting a trip hazard. |
| Resident #3's mattress was torn and springs were visible. |
| Bedroom #12 had only 2 chairs for 3 residents. |
| Residents #1, #4 had no pillow cases on their beds. |
| Residents #1, #5, and #6 had no operable bedside lamps. |
| Lint trap in clothes dryer was caked with lint. |
| Facility did not have the local municipality emergency preparedness plan available. |
| During a fire drill, one resident refused to evacuate due to fear and required wheelchair assistance. |
| Fire drill during sleeping hours was overdue, last conducted in May 2023. |
| Resident #7's record did not include a photograph no more than 2 years old. |
Report Facts
License Capacity: 36
Residents Served: 33
Staffing Hours: 34
Waking Staff: 26
Residents Present During Fire Drill: 34
Residents Evacuated During Fire Drill: 33
Inspection Report
Renewal
Census: 33
Capacity: 36
Deficiencies: 17
Jul 28, 2023
Visit Reason
The inspection was conducted as part of a renewal, complaint, provisional, and incident review process for Heartful Hands LLC, a personal care home.
Findings
The facility was found to be in compliance with 55 Pa. Code Ch. 2600 after multiple inspections. Several deficiencies were identified related to safety, training, sanitary conditions, equipment, and record keeping, all of which had plans of correction accepted and were implemented by November 13, 2023. A follow-up partial inspection on October 20, 2023 found no deficiencies.
Deficiencies (17)
| Description |
|---|
| Carbon monoxide alarms were installed too close to gas furnaces and batteries were not labeled with installation dates. |
| Staff persons present were not certified in first aid or CPR during certain evening hours. |
| Orientation training documentation for a staff person was not dated, making timely completion unverifiable. |
| Staff person did not receive required resident rights training during the 2022 training year. |
| Unsanitary conditions observed including tobacco on resident's sheets, dusty bathroom fan, soiled incontinence pad on bathroom floor, and grime on staircase banister. |
| Overhead light in bedroom #12 was inoperable. |
| Resident #2's bedside table was damaged with exposed sharp staples. |
| Concrete landing at front steps was deteriorated presenting a trip hazard. |
| Resident #3's mattress was torn and springs were visible. |
| Bedroom #12 had only 2 chairs for 3 residents. |
| Residents #1, #5, and #6 had no operable bedside lamps. |
| Lint trap in clothes dryer was caked with lint, creating a fire hazard. |
| The home did not have the emergency preparedness plan for the local municipality posted. |
| During a fire drill, one resident refused to evacuate due to fear, requiring reassessment and wheelchair use. |
| Fire drill during sleeping hours was overdue, with the last conducted in May 2023. |
| Resident #7's record did not include a photograph no more than 2 years old. |
| Resident #1 and #4 had beds without pillow cases. |
Report Facts
Residents present during inspection: 33
Licensed capacity: 36
Total daily staff: 34
Waking staff: 26
Residents receiving Supplemental Security Income: 32
Residents 60 years or older: 22
Residents diagnosed with mental illness: 18
Residents diagnosed with intellectual disability: 4
Residents with mobility need: 1
Inspection Report
Follow-Up
Census: 35
Capacity: 36
Deficiencies: 3
May 19, 2023
Visit Reason
The inspection was an unannounced partial review conducted for provisional, incident, and fine reasons, including a follow-up on a previously submitted plan of correction.
Findings
The report found a substantiated incident of inappropriate touching between residents, deficiencies in fire drill record documentation, and the need for updated resident assessments. The submitted plan of correction was accepted and fully implemented by the follow-up date.
Deficiencies (3)
| Description |
|---|
| Resident #1 intentionally touched resident #2's buttocks inappropriately multiple times, constituting abuse. |
| Fire drill records lacked required details such as the date of the drill and contained inaccurate time descriptions. |
| Resident #1's additional assessment was outdated and did not reflect recent behavioral issues. |
Report Facts
Licensed Capacity: 36
Census: 35
Total Daily Staff: 35
Waking Staff: 26
Residents Receiving Supplemental Security Income: 31
Residents Aged 60 or Older: 25
Residents Diagnosed with Mental Illness: 19
Residents Diagnosed with Intellectual Disability: 3
Residents with Physical Disability: 2
Two Hour Checks for Resident #1: Resident #1 was placed on two-hour checks from 05/20/2023 to 06/15/2023.
Inspection Report
Complaint Investigation
Census: 35
Capacity: 36
Deficiencies: 1
Mar 21, 2023
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection to review compliance at Heartful Hands LLC.
Findings
The facility was found to be non-compliant with administrator staffing requirements, as no qualified administrator was present an average of 20 hours per week. A plan of correction was submitted and fully implemented by June 20, 2023.
Complaint Details
The inspection was triggered by a complaint. The plan of correction was reviewed and determined to be fully implemented as of June 20, 2023.
Deficiencies (1)
| Description |
|---|
| No current, qualified administrator present in the home an average of 20 hours per week. |
Report Facts
License Capacity: 36
Residents Served: 35
Total Daily Staff: 38
Waking Staff: 29
Supplemental Security Income recipients: 30
Residents 60 Years or Older: 35
Residents Diagnosed with Mental Illness: 30
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 3
Residents with Physical Disability: 0
Inspection Report
Complaint Investigation
Census: 35
Capacity: 36
Deficiencies: 1
Dec 28, 2022
Visit Reason
The inspection was a complaint investigation conducted on December 28, 2022, as part of a licensing inspection of Heartful Hands LLC.
Findings
The inspection found violations related to hot water temperatures exceeding the allowed maximum of 120°F in multiple bathrooms. A second provisional license was issued based on an acceptable plan of correction. The facility was required to correct violations by specified dates to avoid fines.
Complaint Details
The inspection was complaint-related as explicitly stated. No substantiation status was provided.
Deficiencies (1)
| Description |
|---|
| Hot water temperature in areas accessible to residents exceeded 120°F, with measurements ranging from 146.2°F to 152.4°F in multiple bathrooms. |
Report Facts
Census at Inspection: 35
Total Capacity: 36
Fine per day: 5
Calculated Fine per day: 175
Mandated Correction Date: 5
Inspection Report
Original Licensing
Census: 33
Capacity: 36
Deficiencies: 2
Jul 12, 2022
Visit Reason
The inspection was conducted due to a change in legal entity for the personal care home, Heartful Hands, LLC, and was a partial licensing inspection as this is a new legal entity operating the home.
Findings
The facility was found to be in substantial compliance with applicable regulations, but the licensing inspector was unable to complete a full inspection. Citations were found related to lighting at bedside and monthly fire drills, which required correction.
Deficiencies (2)
| Description |
|---|
| Resident #1 does not have a source of lighting that can be turned on/off at bedside. |
| Unannounced fire drills were not conducted during the months of March and April 2022. |
Report Facts
License Capacity: 36
Residents Served: 33
Total Daily Staff: 33
Waking Staff: 25
Residents Receiving Supplemental Security Income: 33
Residents Age 60 or Older: 24
Residents Diagnosed with Mental Illness: 18
Residents Diagnosed with Intellectual Disability: 3
Residents with Mobility Need: 0
Residents with Physical Disability: 0
Current Hospice Residents: 0
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