Inspection Reports for The Hearth at Drexel
238 Belmont Ave, Bala Cynwyd, PA 19004, United States, PA, 19004
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Inspection Report
Follow-Up
Census: 74
Capacity: 85
Deficiencies: 3
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.
Deficiencies (3)
| Description |
|---|
| 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
License Capacity: 85
Residents Served: 74
Special Care Unit Capacity: 20
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
Complaint Investigation
Census: 73
Capacity: 85
Deficiencies: 2
Mar 6, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation to review compliance with medication administration and documentation procedures.
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.
Complaint Details
The visit was complaint-related with findings of medication administration errors and documentation issues. The plan of correction was accepted and implemented.
Deficiencies (2)
| Description |
|---|
| 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
License Capacity: 85
Residents Served: 73
Special Care Unit Capacity: 20
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
Renewal
Census: 75
Capacity: 85
Deficiencies: 22
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.
Deficiencies (22)
| Description |
|---|
| 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
License Capacity: 85
Residents Served: 75
Special Care Unit Capacity: 20
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. |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 85
Deficiencies: 9
Jan 26, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation with an unannounced partial inspection on 01/26/2024.
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.
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.
Deficiencies (9)
| Description |
|---|
| 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
License Capacity: 85
Residents Served: 74
Special Care Unit Capacity: 20
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
Complaint Investigation
Census: 72
Capacity: 85
Deficiencies: 3
Nov 21, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation during an unannounced partial inspection on 11/21/2023.
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.
Complaint Details
The inspection was complaint-related and included an incident. The submitted plan of correction was fully implemented as of 02/09/2024.
Deficiencies (3)
| Description |
|---|
| 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
License Capacity: 85
Residents Served: 72
Special Care Unit Capacity: 20
Special Care Unit Residents Served: 19
Current Hospice Residents: 1
Total Daily Staff: 92
Waking Staff: 69
Inspection Report
Renewal
Census: 66
Capacity: 85
Deficiencies: 33
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.
Deficiencies (33)
| Description |
|---|
| 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
License Capacity: 85
Residents Served: 66
Memory Care Capacity: 20
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
Complaint Investigation
Census: 69
Capacity: 85
Deficiencies: 3
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.
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.
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.
Deficiencies (3)
| Description |
|---|
| 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
License Capacity: 85
Residents Served: 69
Special Care Unit Capacity: 20
Special Care Unit Residents Served: 14
Current Hospice Residents: 6
Residents with Mobility Need: 20
Residents 60 Years or Older: 69
Inspection Report
Complaint Investigation
Census: 70
Capacity: 85
Deficiencies: 0
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.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were substantiated.
Report Facts
License Capacity: 85
Residents Served: 70
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 15
Hospice Current Residents: 7
Residents Age 60 or Older: 71
Residents with Mobility Need: 33
Inspection Report
Renewal
Census: 71
Capacity: 85
Deficiencies: 1
Jul 18, 2022
Visit Reason
The inspection was conducted as a renewal review of the facility's compliance with licensing requirements.
Findings
The submitted plan of correction was determined to be fully implemented. One deficiency was noted regarding sanitary conditions where a urinal containing urine was found on a resident's nightstand, and corrective actions were taken including staff in-service and monitoring.
Deficiencies (1)
| Description |
|---|
| A urinal that contained urine was observed on the nightstand of room #E64. |
Report Facts
License Capacity: 85
Residents Served: 71
Special Care Unit Capacity: 20
Special Care Unit Residents Served: 15
Hospice Current Residents: 7
Residents Age 60 or Older: 71
Residents with Mobility Need: 33
Inspection Report
Renewal
Census: 71
Capacity: 85
Deficiencies: 1
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.
Deficiencies (1)
| Description |
|---|
| Sanitary conditions were not maintained as a urine-containing item was observed on a resident's nightstand. |
Report Facts
License Capacity: 85
Residents Served: 71
Special Care Unit Capacity: 20
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
Census: 66
Capacity: 85
Deficiencies: 0
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
License Capacity: 85
Residents Served: 66
Special Care Unit Capacity: 20
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
Census: 63
Capacity: 85
Deficiencies: 0
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
License Capacity: 85
Special Care Unit Capacity: 20
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
Renewal
Census: 63
Capacity: 85
Deficiencies: 5
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.
Deficiencies (5)
| Description |
|---|
| 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
License Capacity: 85
Residents Served: 63
Special Care Unit Capacity: 20
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
Capacity: 85
Deficiencies: 0
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
Maximum capacity: 85
Special Care Unit capacity: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
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