30 Reports
Inspection Report — Jul 1, 2026
Monitoring
Date: Jul 1, 2026
Visit Reason
The inspection was a partial, unannounced monitoring visit conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 07/01/2026.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
Residents Served: 20
Current Hospice Residents: 1
Residents Age 60 or Older: 20
Residents with Mobility Need: 7
Inspection Report — May 20, 2026
Renewal
Date: May 20, 2026
Visit Reason
The inspection was conducted as a renewal visit to assess compliance with licensing regulations at Park Creek Place of North Wales.
Findings
The inspection identified multiple deficiencies related to facility maintenance, medication storage and labeling, fire department notification, preadmission screening documentation, and record legibility. All deficiencies had plans of correction accepted and were implemented by the date of the report.
Citations (7)
88a: Bathroom walls in apartment E4 were in disrepair with multiple scratches and dents.
124: The home lacked documentation of written notification to the local fire department regarding the address, bedroom locations, and evacuation assistance needed.
183e: Resident 1's Lorazepam pill had a punctured foil and expired Acetaminophen was administered to Resident 2.
184a: A bag of 20 syringes of morphine for Resident 3 lacked a pharmacy label with required information.
185a: Resident 4's glucometer displayed an incorrect date and time, indicating calibration issues.
224a: Resident 5's preadmission screening form was completed after admission, not within 30 days prior.
251b: Resident 6's medical evaluation documentation and support plan dates were not legible.
Report Facts
Residents Served: 24
Medication syringes: 20
Expired medication packs: 2
Inspection Report — Apr 13, 2026
Complaint Investigation
Date: Apr 13, 2026
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident at the facility.
Complaint Details
The visit was triggered by an incident involving a resident's suicide attempt and concerns about care appropriateness and safety.
Findings
Multiple deficiencies were identified including abuse related to resident self-harm, failure to perform required criminal background checks, lack of CPR/first aid trained staff during a shift, unsanitary conditions in restrooms, missing fire extinguisher inspection tags, and medication administration errors.
Citations (7)
42b Abuse: A resident with a history of self-harm was admitted without staff being informed of prior suicide attempts. The resident attempted suicide again, resulting in emergency intervention.
51 Criminal Background Check: Staff member hired without an FBI criminal background check as required by state regulations.
63a First Aid/CPR Training: During a shift from 3:00pm to 11:00pm, no staff present were certified in CPR or first aid despite 29 residents being in the home.
85a Sanitary Conditions: Common toilets in two sections of the home were found clogged and visibly soiled with feces, toilet paper, and grime.
131f Fire Extinguisher Inspection: Fire extinguisher outside the common bathroom lacked an inspection tag as required for annual approval.
187b Date/Time of Medication Admin.: Medication records showed administration times when the resident was not present in the home, indicating inaccurate documentation.
187d Follow Prescriber's Orders: Residents did not receive prescribed medications as ordered because the medications were not available in the home.
Report Facts
Residents present during inspection: 29
Inspection Report — Mar 2, 2026
Complaint Investigation
Date: Mar 2, 2026
Visit Reason
The inspection was an unannounced partial inspection triggered by a complaint and incident reported at the facility.
Complaint Details
The inspection was conducted due to a complaint and incident reported at the facility. The complaint was substantiated as multiple violations were found.
Findings
Multiple deficiencies were found including lack of safeguarding system for residents' valuables, incomplete criminal background checks, unqualified direct care staff, incomplete staff training, unsafe resident equipment, snow and ice removal issues, missing bedroom chairs, combustible storage violations, missing fire extinguisher inspection dates, and improper medication administration.
Citations (11)
42x - Safeguard: Residents reported no system to safeguard valuables as all staff have keys to rooms and no lockboxes are provided.
51 - Criminal Background Check: The administrator did not have a completed background check including FBI clearance due to out-of-state residency.
54a - Direct Care Staff: Two direct care staff lacked a high school diploma, GED, or active Pennsylvania nurse aide registry status.
65d - Initial Direct Care Training: A direct care staff member provided unsupervised ADL services without completing required training and competency testing.
65g - Annual Training Content: Staff members B and C did not receive required annual training in fire safety, emergency preparedness, and resident rights.
81b - Resident Personal Equipment: A resident had an unsecured bedside mobility device that slid easily and was not attached to the bed.
100b - Removal Snow/Obstructions: Approximately 1/2 inch of icy snow was present on exterior concrete pathways, posing a hazard.
101j2 - Bedroom Chairs: One resident's bedroom lacked a chair that meets the resident’s needs.
125a - Combustible Storage: Four large paint buckets were stored next to the water heater in the maintenance room, violating clearance requirements.
131f - Fire Extinguisher Inspection: Fire extinguishers in two locations lacked a date of last inspection.
182b - Prescription Medication: Staff person C administered medications without completing required medication administration training.
Report Facts
Residents Served: 27
Current Hospice Residents: 1
Total Daily Staff: 29
Waking Staff: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Administrator | Named in criminal background check deficiency |
| Staff person B | Direct Care Staff | Named in deficiencies for lack of qualifications and missing training |
| Staff person C | Direct Care Staff | Named in deficiencies for lack of qualifications, missing training, and improper medication administration |
Inspection Report — Jun 11, 2025
Follow-Up
Date: Jun 11, 2025
Visit Reason
The inspection was an unannounced partial review conducted due to an incident at the facility.
Findings
The facility was found to have deficiencies related to medication administration, specifically failure to follow prescriber's orders regarding heart rate monitoring before medication administration, and incomplete medication administration training records for staff. The submitted plan of correction was accepted and fully implemented by the facility.
Citations (2)
Failure to document resident's heart rate before administering medication as prescribed (hold if heart rate is less than 60 bpm).
Medication administration training record for staff person A did not include required medication record reviews and only documented one medication administration observation.
Report Facts
Residents Served: 25
Total Daily Staff: 27
Waking Staff: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Educated Medication Technicians on following prescriber's orders and medication error policies; completed audits and monitoring | |
| Executive Director | Oversees Health and Wellness Director ongoing compliance efforts | |
| Certified Medication Train the Trainer | Completed medication administration observations and audits for staff person A |
Inspection Report — May 5, 2025
Renewal
Date: May 5, 2025
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.
Findings
The inspection identified multiple deficiencies including disrepair of surfaces, exterior hazards, lint accumulation in dryers, overdue furnace inspection, smoking outside designated areas, and medication record and administration issues. All deficiencies had plans of correction accepted and were implemented by mid-June 2025.
Citations (10)
Courtyard door frame and gazebo roof were in disrepair with missing and broken wood pieces.
Water hose found on courtyard walkway presenting a hazard.
Approximately 1/2 inch accumulation of lint in the lint trap of the B wing laundry dryer.
Written emergency procedures had not been submitted to the emergency management agency since 02/20/24.
Last furnace inspection was conducted on 12/03/23, overdue for annual inspection.
Staff member was smoking outside the designated smoking area, violating smoke-free policy.
Inaccurate or missing glucose log entries for Resident #1's glucometer readings.
Resident #1's medication administration record did not indicate the number of insulin units administered.
Resident #1's 5/4/25 8am glucose check was completed late at 9:32am.
Resident #2 was not administered prescribed Acetaminophen on 05/05/25 at 2pm despite MAR being initialed as administered.
Report Facts
Residents Served: 27
Staffing Hours: 34
Waking Staff: 26
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 7
Hospice Residents: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Named in multiple findings related to repairs, training, and compliance oversight. | |
| Executive Director | Named in multiple findings related to training, oversight, and compliance monitoring. | |
| Health & Wellness Director | Named in findings related to medication administration, training, and audits. | |
| Assistant Director of Maintenance | Named in training and compliance related to hazard removal and safety rounds. |
Inspection Report — Mar 11, 2025
Date: Mar 11, 2025
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Current Hospice Residents: 3
Residents Age 60 or Older: 30
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 5
Inspection Report — Apr 23, 2024
Original Licensing
Date: Apr 23, 2024
Visit Reason
The inspection was conducted as a new licensing inspection for a new legal entity operating the personal care home facility.
Findings
The facility was found to be in substantial compliance with applicable regulations, and no regulatory citations or deficiencies were identified during the inspection.
Report Facts
Residents Served: 24
Current Residents in Hospice: 3
Residents 60 Years or Older: 24
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 8
Notice — Feb 13, 2024
Date: Feb 13, 2024
Visit Reason
The document serves as a waiver approval for an administrator at Park Creek Place – Personal Care to serve while enrolled in the required 100-hour personal care home administrator training course.
Findings
The waiver is granted under conditions including enrollment in the training course, attendance at orientation, passing the competency test by May 1, 2024, and supervision by a qualified administrator until compliance.
Report Facts
Training hours: 100
Competency test deadline: May 1, 2024
Inspection Report — Oct 19, 2023
Complaint Investigation
Date: Oct 19, 2023
Visit Reason
The inspection was a complaint investigation conducted due to a complaint received regarding resident care and facility compliance.
Complaint Details
The inspection was triggered by a complaint alleging neglect and inadequate care for residents, including failure to respond to call bells, improper transfer leading to a fall, refusal to treat a fungal rash, and insufficient staffing.
Findings
The inspection found multiple deficiencies including delayed assistance with activities of daily living, neglect in resident care leading to falls and untreated conditions, inadequate staffing levels, lack of bedside lighting for a resident, and incomplete resident records missing hair and eye color information.
Citations (6)
Residents 1, 2, and 3 are not receiving timely care for toileting, bowel movements, and transferring as required by their support plans; call bells were pressed with no staff response for over an hour.
Resident 1 fell while being transferred and rolled off the bed due to staff neglect.
Resident 4 had a fungal rash staff refused to treat, causing worsening condition and odor leading to resident embarrassment and isolation.
The home lacks adequate staffing to meet residents' needs, especially for two-person assistance with Hoyer lifts.
Resident 1 does not have access to an operable lamp or source of light at bedside.
Resident records for residents 3, 4, 5, and 6 do not include hair or eye color.
Report Facts
Residents Served: 32
Deficiency Completion Date: Jan 31, 2024
Plan of Correction Submission Dates: Nov 20, 2023
Plan of Correction Implementation Date: Nov 29, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Named in multiple findings and plan of correction activities including audits, training, and corrective actions | |
| Director of Maintenance | Involved in checking pendant system and placing bedside lamp | |
| Health and Wellness Director | Responsible for staff training and in-service on regulations and policies | |
| Assistant Nurse | Supplied with pager with timed escalation feature as part of corrective action |
Inspection Report — Apr 5, 2023
Complaint Investigation
Date: Apr 5, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation at Park Creek Place - Personal Care on 04/05/2023.
Complaint Details
The visit was complaint-related, investigating medication discrepancies and errors. The submitted plan of correction was determined to be fully implemented.
Findings
The inspection identified medication procedure violations including discrepancies in narcotics counts and missing initials on medication administration records. The facility submitted a plan of correction which was accepted and fully implemented by 05/23/2023.
Citations (2)
Discrepancies in narcotics counts where staff person A recorded fewer tablets than actually present and misappropriated medication.
Medication administration records for Resident 1 and Resident 2 lacked initials of staff who administered medications at specified times.
Report Facts
Residents Served: 38
Total Daily Staff: 48
Waking Staff: 36
Current Residents in Hospice: 1
Residents Age 60 or Older: 38
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person A | Named in medication misappropriation and narcotics count discrepancy | |
| Care Services Manager | CSM | Involved in medication destruction, audits, and staff training |
| Assistant Care Services Manager | ACSM | Involved in medication replacement, audits, and staff queries |
| Medication Technician | Named in late entry documentation and medication administration record corrections |
Inspection Report — Jan 31, 2023
Follow-Up
Date: Jan 31, 2023
Visit Reason
The inspection visit was conducted as a follow-up to verify the implementation of a previously submitted plan of correction related to an incident.
Findings
The submitted plan of correction was found to be fully implemented, addressing deficiencies related to activities of daily living assistance, abuse, and missed meals. Continued compliance must be maintained.
Citations (3)
Resident 1 did not receive required assistance with toileting as indicated in their assessment and support plan.
Resident 1 pressed call pendant for toileting, shower, and lunch assistance but staff delayed response by over 3 hours, resulting in missed lunch without replacement meal offered.
Resident 1 missed lunch meal and was not offered a replacement meal after delayed staff response.
Report Facts
Residents served: 47
Current hospice residents: 4
Residents diagnosed with mental illness: 5
Residents with mobility need: 21
Residents 60 years or older: 47
Inspection Report — Jan 9, 2023
Renewal
Date: Jan 9, 2023
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.
Findings
Multiple deficiencies were identified related to hot water temperature, furniture and equipment safety, medication storage and administration, support plan documentation, and record entries. The facility submitted a plan of correction which was determined to be fully implemented.
Citations (7)
Hot water temperature in resident rooms exceeded the maximum allowed 120°F, measuring between 122.5°F and 123.4°F.
Enabler bed bar with a 6" opening on resident 1's bed did not have a cover.
Prescription medications, OTC medications, CAM and syringes were unlocked, unattended, and accessible in the bathroom of Resident 1's room.
Resident 1 had OTC medications in their bathroom that were not currently prescribed and not included on the Medication Administration Record.
Medication cart was left unlocked and unattended for 10 minutes; glucometer belonging to resident 2 was not calibrated correctly.
Resident 1's support plan did not indicate the degree of need for toileting assistance.
Resident 2's Medication Administration Record had multiple illegible and unclear scribbled out entries.
Report Facts
Residents Served: 41
Staffing Hours: 56
Waking Staff: 42
Hot Water Temperature: 123.4
Hot Water Temperature: 122.7
Hot Water Temperature: 122.5
Medication Cart Unattended Time: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person A | Left medication cart unlocked and unattended; later locked the cart upon return. | |
| Care Services Manager | CSM | Placed cover on bed enabler, secured medications, conducted assessments and education related to medication administration and compliance. |
| Assistant Care Services Manager | ACSM | Updated resident support plan to reflect degree of need for toileting assistance. |
| Regional Director of Facilities Management | RDFM | Educated Executive Director and Maintenance Technician on hot water temperature requirements. |
| Maintenance Technician | Lowered hot water temperature, audited water temperatures, and ensured compliance. |
Inspection Report — Nov 15, 2022
Follow-Up
Date: Nov 15, 2022
Visit Reason
The inspection visit on 11/15/2022 was a partial, unannounced incident inspection to review compliance and verify the submitted plan of correction.
Findings
The facility had multiple deficiencies including unsigned resident-home contracts, inadequate staffing to meet resident needs, delayed food service, and direct care staff providing unsupervised ADL services without completing required training. The submitted plan of correction was accepted and fully implemented by 01/24/2023.
Citations (4)
Resident-home contract for resident #1 was not signed by the resident.
Resident #2 did not receive management as required by his/her assessment and support plan due to lack of available direct care staffing.
Food service was delayed due to lack of staff to complete tasks, resulting in residents not receiving requested items and staff having to multitask.
Direct care staff person C provided unsupervised ADL services before completing and passing the Department-approved direct care training course and competency test.
Report Facts
Residents Served: 47
Current Residents in Hospice: 5
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 21
Residents Age 60 or Older: 47
Total Daily Staff: 68
Waking Staff: 51
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Assisted resident #2 with management per assessment and support plan | |
| Staff member B | Provided resident #2 a drink of water during inspection | |
| Staff person C | Provided unsupervised ADL services before completing required training | |
| Regional Executive Director | RED | Educated staff and oversaw plan of correction implementation |
| Executive Director | ED | Completed audits and implemented corrective actions |
| Community Relations Manager | CRM | Educated on contract signature requirements |
| Care Services Manager | CSM | Involved in education and auditing related to staffing and care plans |
| Regional Director of Care Services | RDCS | Educated staff on care requirements |
Inspection Report — Jul 19, 2022
Follow-Up
Date: Jul 19, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident, to review the submitted plan of correction and verify compliance.
Findings
The facility was found to have implemented the submitted plan of correction related to allegations of abuse, assistance with activities of daily living, treatment of residents with dignity and respect, staff hiring practices, and resident assessments. No residents were negatively affected by the deficiencies, and audits and staff education were implemented to ensure ongoing compliance.
Citations (6)
Failure to develop and implement a plan of supervision or suspend a staff person involved in an alleged abuse incident.
Delay in providing assistance with toileting resulting in resident being soiled.
Resident was left on the floor after a fall and was handled roughly by staff causing pain and injury.
Resident was treated without dignity and respect during a fall incident, including arguing with the resident.
Staff hiring process deficiency: criminal background check was not completed prior to staff starting work.
Resident initial assessment did not include assessment for short term memory.
Report Facts
Residents Served: 44
Current Residents in Hospice: 3
Residents 60 Years or Older: 44
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 19
Total Daily Staff: 63
Waking Staff: 47
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person A | Named in findings related to abuse allegations, suspension, and return to work without plan of supervision. | |
| Staff Person B | Named in findings related to abuse, rough handling of resident, suspension, and completion of abuse training. | |
| Staff Person C | Named as staff member involved in assisting resident after fall and witnessing staff behavior. | |
| Regional Executive Director | RED | Educated staff on regulatory requirements and policies. |
| Care Services Manager | CSM | Conducted audits, in-serviced staff, and monitored compliance. |
| Assistant Care Services Manager | ACSM | Assisted with staff in-service and audits. |
Inspection Report — May 23, 2022
Plan of Correction
Date: May 23, 2022
Visit Reason
The document is a follow-up review of the submitted plan of correction for the facility conducted by the Pennsylvania Department of Human Services on 05/23/2022.
Findings
The submitted plan of correction was determined to be fully implemented, and continued compliance must be maintained.
Inspection Report — Feb 18, 2022
Complaint Investigation
Date: Feb 18, 2022
Visit Reason
The inspection was conducted as a complaint and incident investigation to review compliance with resident care and safety regulations.
Complaint Details
The complaint investigation found substantiated neglect and verbal abuse by an agency staff person who failed to provide required two-person assistance during transfer, resulting in injury to resident #1.
Findings
The inspection found multiple deficiencies related to inadequate assistance with activities of daily living, verbal abuse and neglect by staff, incomplete medical evaluations, and insufficient documentation in resident support plans. The facility submitted a plan of correction which was determined to be fully implemented.
Citations (7)
Resident #1 did not receive required two-person assistance for toileting, resulting in injury during transfer.
Resident #1 was subjected to verbal abuse and neglect by agency staff person A during transfer.
Staff person A did not receive required fire safety and emergency preparedness orientation on first day of work.
Staff person A did not complete required orientation within 40 hours on resident rights, emergency medical plan, and mandatory reporting of abuse and neglect.
Medical evaluation for resident #1 was not completed within required timeframe prior to or after admission.
Resident #1's medical evaluation did not include current medical diagnoses of Von Willerbrand Disease, breast cancer, and hyperlipidemia.
Resident #1's support plan did not document how medical diagnoses of Osteoarthritis, Major Depressive Disorder, and Kyphosis would be met.
Report Facts
Residents Served: 37
Current Hospice Residents: 1
Residents with Mobility Need: 12
Total Daily Staff: 49
Waking Staff: 37
Direct Care Staff Present on Shift: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person A | Agency CNA | Named in findings related to neglect, verbal abuse, failure to provide required assistance, and incomplete orientation. |
| Shawn Parker | Signed the cover letter regarding plan of correction implementation. |
Inspection Report — Sep 29, 2021
Renewal
Date: Sep 29, 2021
Visit Reason
The inspection was a full, unannounced renewal inspection conducted on 09/29/2021 to review compliance with licensing requirements for Park Creek Place - Personal Care.
Findings
The inspection identified deficiencies related to unsigned resident-home contracts, missing signed statements acknowledging receipt of resident rights and complaint procedures, lack of submission of emergency procedures to the local emergency management agency, and failure to educate residents on their right to refuse medication. Plans of correction were submitted and accepted, with follow-up audits and education planned.
Citations (4)
Resident-home contracts for residents #1, #2, and #3 were not signed by the residents.
Resident #1 and #2's records did not contain signed statements acknowledging receipt of resident rights and complaint procedures.
The home's written emergency procedures had not been submitted to the local emergency management agency; the date of last submission was unknown.
Residents #1 and #2 had not been educated on their right to refuse medication if they believed there was a medication error.
Report Facts
Residents Served: 41
Current Hospice Residents: 2
Residents 60 Years or Older: 40
Residents with Mobility Need: 15
Residents with Physical Disability: 1
Total Daily Staff: 56
Waking Staff: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Director of Care Services | RDCS | Educated Executive Director and Community Relations Manager on regulatory requirements and emergency procedures. |
| Executive Director | ED | Completed internal audits, submitted emergency procedures, and involved in education and corrective actions. |
| Community Relations Manager | CRM | Educated on regulatory requirements and involved in corrective actions. |
| Community Services Manager | CSM | Educated residents on their right to refuse medication. |
Inspection Report — May 10, 2021
Monitoring
Date: May 10, 2021
Visit Reason
The inspection was a partial, unannounced monitoring visit conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 05/10/2021 to assess compliance with licensing requirements at Park Creek Place - Personal Care.
Findings
The inspection identified a deficiency related to the refund process following the death of a resident. Specifically, the facility failed to provide proof of refund to the estate of a deceased resident in a timely manner. The facility submitted an acceptable plan of correction addressing the issue, including staff education and auditing procedures to ensure compliance.
Citations (1)
Failure to provide proof of refund to the estate of a deceased resident within the required timeframe.
Report Facts
Residents Served: 35
Total Daily Staff: 45
Waking Staff: 34
Current Hospice Residents: 1
Residents with Mobility Need: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Specialist | Returned funds to deceased resident's designated person and was educated on refund requirements. | |
| Executive Director | Educated Administrative Specialist and conducted audits related to deceased resident refunds. |
Inspection Report — Dec 22, 2020
Complaint Investigation
Date: Dec 22, 2020
Visit Reason
The inspection was conducted as a partial, unannounced investigation triggered by an incident involving missing resident funds and related compliance concerns.
Complaint Details
The investigation was initiated due to a complaint/incident involving the theft of resident funds by Staff Member A. The complaint was substantiated based on findings of missing funds and failure to report the incident timely.
Findings
The facility was found to have multiple violations related to financial management, abuse reporting, safeguarding resident funds, criminal background checks, medical evaluations, medication records, and medication storage procedures. Staff member A was found to have taken resident funds without timely reporting, and the facility lacked adequate policies and controls for safeguarding resident money.
Citations (10)
2600.16c - The home failed to report the theft of resident funds totaling $3288.61 within 24 hours to the Department as required.
2600.20b4 - Staff member A took $1788.61 of resident funds from the home's safe without authorization.
2600.20b6 - The home did not offer assistance to Residents #7 and #8 in establishing interest-bearing accounts despite holding over $200 for more than two months.
2600.20b8 - Resident #9 did not receive a quarterly itemized account of financial transactions as required.
2600.42b - Staff member A was observed removing resident funds without permission, constituting abuse and neglect.
2600.42x - The home lacked a policy describing access to the safe and failed to safeguard resident funds properly.
2600.51 - Staff member A did not have a Pennsylvania State Police Criminal Background Check on file as required.
2600.141a - Resident #10's medical evaluation was not completed within 60 days prior to or 30 days after admission.
2600.181f - Resident #10's medication record did not include a current list of medications, missing Vicodin.
2600.185a - The home failed to have Oxycodone 5mg available for Resident #10 as prescribed on 12/20/20.
Report Facts
Resident funds stolen: 3288.61
Residents served: 37
Staff count: 48
Waking staff: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member A | Named in multiple findings related to theft of resident funds, abuse, and lack of criminal background check. | |
| Claire Mendez | Regional Director of Care Services (RDCS) | Educated facility staff on regulations and oversaw audits and corrective actions. |
| Executive Director (ED) | Executive Director | Received education and responsible for auditing and corrective actions. |
| Care Services Manager (CSM) | Care Services Manager | Received education and involved in audits and corrective actions. |
| Community Relations Manager (CRM) | Community Relations Manager | Received education and involved in audits and corrective actions. |
| Administrative Assistant | Administrative Assistant | Responsible for safeguarding safe key and maintaining Safe Access Log. |
| Assistant Care Services Manager (ACSM) | Assistant Care Services Manager | Received education and involved in audits and corrective actions. |
| LPN | Licensed Practical Nurse | Educated on medication regulations. |
| Medication Technicians | Medication Technicians | Educated on medication regulations. |
Inspection Report — Dec 17, 2019
Renewal
Date: Dec 17, 2019
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Services Licensing on December 17 and 18, 2019, to determine compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
The facility was found to be in compliance with applicable regulations and a regular license was issued. One deficiency was cited related to the failure of an administrator to complete an orientation program prior to initial employment, which was later corrected.
Citations (1)
2600.64a: Staff person A did not complete an orientation program approved and administered by the Department prior to initial employment as an Administrator.
Report Facts
Resident Support Staff: 63
Total Daily Staff: 133
Waking Staff: 100
Residents Served: 53
Current Residents Hospice: 5
Residents Age 60 or Older: 53
Residents with Mobility Need: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lori Bellport | Administrator | Named in relation to the orientation program deficiency and plan of correction |
Inspection Report — Oct 18, 2019
Follow-Up
Date: Oct 18, 2019
Visit Reason
The visit was a partial, unannounced inspection conducted due to an incident to review the submitted plan of correction and verify compliance.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing multiple deficiencies related to staff training, medication administration, and resident assessments. Continued compliance must be maintained.
Citations (6)
Regulation 2600.65e: Direct care staff person A's annual training for 2018 was not available and could not be verified.
Regulation 2600.65f: Direct care staff person A did not receive training in the specified topics in 2600.65f in 2018.
Regulation 2600.65g: Direct care staff person A did not receive training in the specified topics in 2600.65g in 2018.
Regulation 2600.187b: Resident #1 and #2 were not administered prescribed medications on 10/4/2019 as ordered, and documentation was inaccurate.
Regulation 2600.187d: Resident #1 was prescribed medication not administered on 10/4/2019 because it was unavailable until 10/5/2019.
Regulation 2600.225a: Resident #1's initial assessment was not completed until 7/2/2019, despite admission on 10/23/2018.
Report Facts
Residents Served: 51
Current Residents - Hospice: 5
Resident Support Staff: 63
Total Daily Staff: 126
Waking Staff: 95
Residents Age 60 or Older: 57
Residents with Mobility Need: 12
Residents with Physical Disability: 1
Inspection Report — Aug 19, 2019
Monitoring
Date: Aug 19, 2019
Visit Reason
The inspection was a partial, unannounced visit conducted for provisional monitoring of compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
Violations were found related to medication storage procedures and medication administration documentation. Plans of correction were submitted and partially implemented to address these issues.
Citations (2)
2600.185a: The home failed to have Bisacodyl 5 MG Tablet available on 08/19/19 as prescribed for resident #1. Medications were audited and re-education was provided to ensure availability on medication carts.
2600.187b: Staff did not record the date and time of administration for Lorazepam 1 MG Tablet given to resident #2 on 08/13/19 at 8:50 am. Audits and re-education were conducted to ensure proper documentation.
Report Facts
Residents Served: 52
Current Hospice Residents: 5
Residents with Mobility Need: 12
Residents 60 Years or Older: 52
Residents with Physical Disability: 1
Total Daily Staff: 64
Waking Staff: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joe Detzner | Administrator | Named as facility administrator in the violation report |
| Lori Bellport | Executive Director | Signed plan of correction documents |
| Dean Gray | On-site Department Representative during inspection |
Inspection Report — May 24, 2019
Renewal
Date: May 24, 2019
Visit Reason
The document is a renewal license issued in response to the May 23, 2019 renewal application to operate Park Creek Place - Personal Care. The Department advises that an onsite inspection will be conducted within the next twelve months as part of the annual inspection requirement.
Findings
No inspection findings are reported in this document. It serves as a license renewal certificate and notification of future inspection requirements.
Inspection Report — Oct 25, 2018
Renewal
Date: Oct 25, 2018
Visit Reason
The inspection was a renewal inspection conducted on October 25, 2018, with an interim inspection on March 12, 2019, to assess compliance with licensing requirements for Park Creek Place - Personal Care.
Findings
Multiple violations of Pennsylvania Code Chapter 2600 related to Personal Care Homes were found, including issues with resident contracts, medical evaluations, criminal background checks, medication administration, resident rights, and staff qualifications. Plans of correction were developed but many were only partially implemented or not implemented as of the last review.
Citations (20)
2600.25(b) - Resident contracts for residents 1 and 2 were not signed by the residents as required.
2600.41(d) - Resident records did not contain statements signed by residents acknowledging receipt of rights and complaint procedures.
2600.51 - Criminal history checks for staff person A were not completed prior to hire and for staff person B were incomplete.
2600.54(a) - Direct care staff persons A and C lacked required high school diploma, GED, or active Pennsylvania nurse aide registry status.
2600.141(b)(1) - Residents 3 and 4 did not have timely annual medical evaluations completed.
2600.185(a) - Resident 1's medication Ondansetron HCL 4 mg was not available on medication cart as prescribed.
2600.187(d) - Resident 7 was not administered prescribed Cholecalciferol 30mg daily as ordered.
2600.187(d) - Resident 3 was not administered prescribed Warfarin Sodium 1.5 tablets on Mondays and Fridays as ordered.
2600.187(d) - Resident 5 was not administered prescribed Cymbalta 40mg once daily as ordered.
2600.191 - Residents 1 and 2 were not educated on their right to refuse medication and potential medication errors.
2600.224(a) - Resident 6 lacked a preadmission screening form as required.
2600.226(a) - Resident 7's initial assessment was not completed within 15 days of admission.
2600.227(a) - Residents 1, 2, 3, 6, and 7 did not have completed support plans signed by participants within 30 days of admission.
2600.227(d) - Resident 8's support plan was not signed by all participants involved in its development.
2600.65(d) - Direct care staff person D hired after April 24, 2006, lacked required training and competency testing.
2600.65(g) - Direct care staff person E did not receive the required 12 hours of annual training for 2018.
2600.65(g) - Direct care staff person E was missing training hours for 2018.
2600.65(g) - Staff person E was scheduled to receive missing training within 30 days.
2600.65(g) - Staff person E was missing training in fire safety, emergency preparedness, resident rights, and Older Adult Protective Services Act topics for 2018.
2600.187(d) - Resident 5's Vitamin D3 2000 units prescribed daily was not administered and documentation was lacking.
Report Facts
Number of Residents Served: 63
Number of Current Hospice Residents: 5
Number of Residents Age 60 or Older: 63
Number of Residents with Mobility Need: 18
Number of Residents Served: 59
Number of Residents Age 60 or Older: 59
Number of Residents with Mobility Need: 12
Number of Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Gardner | Legal Entity Representative | Signed multiple plans of correction and violation reports |
| Joe Detzner | Legal Entity Representative | Signed plans of correction and violation reports for monitoring inspection |
Inspection Report — Jul 3, 2018
Complaint Investigation
Date: Jul 3, 2018
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident involving alleged abuse of a resident by staff members.
Complaint Details
The complaint involved an allegation of abuse against resident #1 by staff persons A, B, and C. The home failed to report the allegation timely and did not implement required supervision or suspension of involved staff. The complaint was substantiated by the findings.
Findings
Multiple violations of Pennsylvania Code 55 Pa.Code Chapter 2600 were found, including failure to report suspected abuse, failure to submit a plan of supervision or suspension for involved staff, improper use of restraints, and inadequate resident assessment. Plans of correction were partially implemented as of the report date.
Citations (4)
55 Pa.Code 2600.15(a) - The home did not report the allegation of abuse against resident #1 to the local area agency on aging until 07/05/18.
55 Pa.Code 2600.15(b) - The home did not develop and implement a plan of supervision or suspend staff persons A, B, and C involved in the alleged abuse of resident #1.
55 Pa.Code 2600.202 - Staff members A, B, and C did not follow policies regarding care for a resident with combative behaviors and improperly restrained resident #1 by holding the resident's wrists.
55 Pa.Code 2600.227(c) - The support plan for resident #1 dated 04/10/18 did not address ongoing falls exhibited since January 2018.
Report Facts
Number of Residents Served: 67
Number of Current Hospice Residents: 4
Number of Hospice Residents in past year: 10
Number of Caregivers Scheduled on Incident Day: 4
Notice — May 8, 2018
Date: May 8, 2018
Visit Reason
This document serves as a renewal notification and license issuance for Park Creek Place - Personal Care Home, confirming the facility's authorized capacity and informing about the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It only confirms the issuance of a regular license following the renewal application.
Report Facts
Inspection Report — Mar 13, 2017
Annual Inspection
Date: Mar 13, 2017
Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing inspections for Park Creek Place - Personal Care on March 13, 2017 and May 5, 2017, to assess compliance with 55 Pa.Code Chapter 2600 relating to Personal Care Homes.
Findings
Multiple violations were found related to resident contracts, receipt of resident rights and complaint procedures, criminal background checks, medical evaluations, medication administration, resident education on medication refusal, initial assessments, and support plan signatures. Plans of correction were submitted and partially implemented as of the report dates.
Citations (11)
Regulation 55 Pa.Code §2600.26(b): The contract for Residents #1 and #2 was not signed by the resident.
Regulation 55 Pa.Code §2600.41(c): Records for Residents #1 and #2 did not contain a statement signed by the resident acknowledging receipt of resident rights and complaint procedures.
Regulation 55 Pa.Code §2600.51: Criminal background checks were not requested timely for Staff Members A and B.
Regulation 55 Pa.Code §2600.141(a)(2): Medical evaluation for Resident #2 dated 2/2/17 did not include required elements #4, #6-#8, and #10.
Regulation 55 Pa.Code §2600.183(d): Discontinued medication Hydroalazine HCL 10 MG was observed in the medication cart.
Regulation 55 Pa.Code §2600.185(a): Resident #4's glucometer was not calibrated to correct date and time.
Regulation 55 Pa.Code §2600.191: Residents #1 and #2 were not educated on their right to refuse medication if they believe there is a medication error.
Regulation 55 Pa.Code §2600.226(a): Resident #1's and #5's support plans were incomplete.
Regulation 55 Pa.Code §2600.227(g): Residents #1, #2, #6, and #7 did not sign their support plans.
Regulation 55 Pa.Code §2600.182(c): Medication administration records for Residents #1 and #2 were missing glucometer readings and had inaccurate documentation.
Regulation 55 Pa.Code §2600.187(b): Medication administration records for Resident #2 had entries recorded at wrong times and by unlicensed staff.
Report Facts
Number of Residents Served: 64
Number of Residents Served: 68
Total Daily Staff: 74
Waking Staff: 66
Total Daily Staff: 69
Waking Staff: 67
Number of Current Hospice Residents: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julia Monroe | Administrator | Named as responsible party for continued compliance and signed multiple plans of correction |
Inspection Report — Oct 24, 2016
Original Licensing
Date: Oct 24, 2016
Visit Reason
The inspection was conducted due to a change in legal entity for the facility.
Findings
The facility was found to be in substantial compliance with regulations but was unable to complete a full inspection due to being a new legal entity. Several violations were identified and must be corrected as specified in the License Inspection Summary.
Citations (4)
Regulation 2600.85(a): The carpet inside room A-9 had a pungent odor near the resident's bed and night stand.
Regulation 2600.85(d): The trash can in the main kitchen does not have a lid.
Regulation 2600.103(e): Food served and returned from an individual's plate was not labeled or dated in the main kitchen freezer.
Regulation 2600.103(g): Two 10-lb bags of rice in the main kitchen food pantry were opened and unsealed.
Report Facts
Number of Residents Served: 58
Number of Current Hospice Residents: 7
Number of Hospice Residents in past year: 10
Number of Residents 60 Years or Older: 58
Number of Residents with Mental Illness: 4
Number of Residents with Mobility Need: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darlene Klamerus | Administrator | Named in facility header on violation report |
| Kevin Caruso | Administrator / Executive Director | Named as legal entity representative signing plan of correction pages |
| Lissette Colon | Department representative on-site during inspection |
Notice — October 15, 2021
Date: October 15, 2021
Visit Reason
The document serves as a renewal notice and license issuance for the Personal Care Home 'Park Creek Place' following receipt of the renewal application dated October 14, 2021. It also advises that an annual inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document; it confirms issuance of a regular license and outlines the requirement for a future annual inspection.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notice letter. |
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