Inspection Report
Follow-Up
Census: 39
Capacity: 75
Deficiencies: 4
Sep 16, 2025
Visit Reason
The visit was a partial, unannounced inspection conducted as a follow-up to verify the implementation of a previously submitted plan of correction related to a fine.
Findings
The inspection found that the submitted plan of correction was fully implemented, addressing deficiencies related to evacuation times, medication storage and calibration, medication record documentation, and following prescriber's orders for blood glucose testing.
Deficiencies (4)
| Description |
|---|
| Evacuation time during fire drill exceeded the allowed 8 minutes by 6 seconds. |
| Resident glucometer was not calibrated to the current date and time, and discrepancies were found between glucometer readings and Medication Administration Records (MAR). |
| Medication record did not indicate insulin units administered by scheduled times as prescribed. |
| Blood glucose readings were not completed as ordered for multiple residents. |
Report Facts
License Capacity: 75
Residents Served: 39
Evacuation Time: 486
Allowed Evacuation Time: 480
Total Daily Staff: 54
Waking Staff: 41
Current Hospice Residents: 5
Inspection Report
Census: 40
Capacity: 75
Deficiencies: 0
Sep 10, 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 as a result of this inspection.
Report Facts
Residents Served: 40
License Capacity: 75
Current Hospice Residents: 5
Residents Age 60 or Older: 40
Residents with Mobility Need: 15
Inspection Report
Plan of Correction
Census: 42
Capacity: 75
Deficiencies: 11
Jun 17, 2025
Visit Reason
The inspection and review were conducted as follow-up visits on 06/17/2025, 07/18/2025, 07/29/2025, and 07/30/2025 to verify that the submitted plan of correction was fully implemented.
Findings
The facility was found to have multiple deficiencies related to incident reporting, fire drills, fire alarm testing, medical evaluations, menu posting, medication storage and administration, resident assessments, and support plan completion. The submitted plan of correction was accepted and fully implemented by 09/22/2025.
Deficiencies (11)
| Description |
|---|
| The home failed to report fire alarm incidents to the department within 24 hours. |
| Unannounced fire drills were not held during May, June, and July 2025. |
| Fire drill records were incorrectly documented and the fire alarm was disabled during a drill. |
| A fire alarm or smoke detector was not properly set off during each fire drill. |
| Resident medical evaluations were not completed at least annually. |
| Menus were not posted one week in advance as required. |
| Procedures for safe storage, access, security, distribution, and use of medications were not properly followed, including inaccurate blood glucose documentation. |
| Medication records did not include frequency of administration or date and time of medication administration as required. |
| The home failed to follow prescriber's orders for medication administration, including incorrect dosages and missed doses. |
| Resident additional assessments did not include all medical conditions. |
| Resident support plans were not developed and implemented within 30 days of admission. |
Report Facts
License Capacity: 75
Residents Served: 42
Current Residents: 7
Staff Total Daily: 58
Staff Waking: 44
Fire Drills Missed: 3
Inspection Report
Renewal
Census: 48
Capacity: 75
Deficiencies: 13
Apr 1, 2025
Visit Reason
The inspection was conducted as a renewal licensing inspection of the Personal Care Home facility Maidencreek Place.
Findings
Multiple violations of 55 Pa. Code Chapter 2600 were found during the inspection, including deficiencies in staff orientation, fire safety drills, medication administration, and support plan documentation. A provisional license was issued due to these violations, with a plan of correction required.
Deficiencies (13)
| Description |
|---|
| Staff Member A did not complete an orientation on fire safety and emergency preparedness on or before the first day worked. |
| Staff Member A did not receive training on resident rights, emergency medical plan, mandatory reporting of abuse and neglect, or reporting of reportable incidents within 40 scheduled working hours. |
| Fire drill conducted on 9/27/24 did not note how many residents evacuated during the drill. |
| Fire drills exceeded the evacuation time determined by a Fire Safety Expert; drills on 6/24/24 and 9/17/24 took longer than allowed. |
| Sleeping hours fire drill was not conducted as required; last drill was on 9/17/24 and not again until 3/27/25. |
| Annual medical evaluation was not completed for Resident #1 in 2024. |
| Excess of 15 cigarette butts observed on the ground in the designated smoking area. |
| Menus were not posted in the home at the time of inspection. |
| Resident #5's PRN prescription medication was not available in the medication cart at the time of inspection. |
| Medication Administration Records for Residents #2 and #3 did not list the number of units of insulin administered. |
| Resident #4 was administered medication despite prescriber instructions to hold medication for systolic blood pressure under 110 on multiple dates. |
| Resident #2 received Trulicity injections administered by Med Tech staff without a waiver for non-licensed staff to administer medication. |
| Resident #6's support plan was not signed by the resident, and it was not noted if the resident refused or was unable to sign. |
Report Facts
License Capacity: 75
Residents Served: 48
Current Residents in Hospice: 4
Residents with Mobility Need: 11
Staffing Hours - Total Daily Staff: 59
Staffing Hours - Waking Staff: 44
Fine Amount Per Day: 210
Fine Per Resident Per Day: 5
Census at Inspection: 42
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed the letter regarding the provisional license and enforcement actions. |
| Marc Heil | Listed as contact in legal entity address. |
Inspection Report
Complaint Investigation
Census: 37
Capacity: 75
Deficiencies: 0
Feb 7, 2025
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident.
Findings
No regulatory citations or deficiencies were identified as a result of the inspection.
Complaint Details
The inspection was incident-related and no deficiencies were found, indicating no substantiated complaints.
Report Facts
Total Daily Staff: 46
Waking Staff: 35
Resident Support Staff: 0
Residents Served: 37
License Capacity: 75
Current Hospice Residents: 3
Residents Age 60 or Older: 37
Residents with Mobility Need: 9
Residents with Physical Disability: 1
Inspection Report
Follow-Up
Census: 35
Capacity: 75
Deficiencies: 3
Jul 31, 2024
Visit Reason
The inspection visit on 07/31/2024 was a partial, unannounced follow-up to review the implementation of a plan of correction related to an incident at the facility.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing issues including failure to provide immediate access to requested documents, delayed incident reporting, and staff misconduct involving verbal and physical altercations. Continued compliance is required.
Deficiencies (3)
| Description |
|---|
| Failure to provide immediate access to the home, residents, and records to agents of the Department upon request. |
| Incident involving verbal and physical altercation between staff was reported to the Department exceeding the 24-hour reporting requirement. |
| Residents were not treated with dignity and respect due to staff verbal and physical altercation in resident rooms. |
Report Facts
License Capacity: 75
Residents Served: 35
Current Hospice Residents: 3
Total Daily Staff: 45
Waking Staff: 34
Residents with Mobility Need: 10
Inspection Report
Follow-Up
Census: 36
Capacity: 75
Deficiencies: 3
May 1, 2024
Visit Reason
The visit was an unannounced partial inspection conducted as an interim review to verify the submitted plan of correction was fully implemented.
Findings
The inspection found deficiencies related to medication administration training and documentation, following prescriber's orders, and support plan documentation for medical/dental needs. The submitted plan of correction was accepted and determined to be fully implemented as of the inspection date.
Deficiencies (3)
| Description |
|---|
| Medication administration was performed by staff without documented required Medication Administration Training or observations. |
| Failure to follow prescriber's orders due to missing blood pressure recordings affecting medication administration decisions. |
| Support plan inaccurately documented resident's use of hearing aids which were denied by the resident and not found in the room. |
Report Facts
Residents Served: 36
License Capacity: 75
Current Residents in Hospice: 3
Residents Age 60 or Older: 36
Residents with Mobility Need: 10
Inspection Report
Renewal
Census: 36
Capacity: 75
Deficiencies: 9
Apr 23, 2024
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 04/23/2024, including an incident review and follow-up on plan of correction submissions.
Findings
The inspection identified multiple deficiencies related to compliance with health and safety laws, staff qualifications and training, resident assessments, medication storage, and support plans. All deficiencies had accepted plans of correction which were implemented by 06/24/2024.
Deficiencies (9)
| Description |
|---|
| The home does not have a policy that outlines the use of bedside mobility devices; 4 residents are using bed enablers without proper documentation. |
| Personnel file for direct care staff member A did not contain a PA background check meeting OAPSA requirements. |
| Direct care staff person B lacked documentation of a GED or high school diploma. |
| Direct care staff persons A and C did not receive required training on dementia care, infection control, safe management, fire safety, emergency preparedness, resident rights, and falls prevention during training year 2023. |
| Resident rooms #16 and #51 lacked operable bedside lamps within reach of the bed. |
| The home failed to conduct required sleeping hour fire drills every six months; last drill was on 6/14/23. |
| Resident #2 had barrier cream and Miconazole 2% powder unlocked and accessible in the bathroom, contrary to self-administration assessment and medication storage requirements. |
| The initial assessment (RASP) for Resident #3 was not completed within 15 days of admission. |
| Support plans for Residents #4 and #5 did not document specific needs, intended use, risks, or FDA compliance information for bed enablers in use. |
Report Facts
Residents served: 36
License capacity: 75
Current hospice residents: 3
Residents with mobility need: 5
Staffing hours: 41
Waking staff hours: 31
Residents using bed enablers: 4
Inspection Report
Follow-Up
Census: 41
Capacity: 75
Deficiencies: 12
Jan 31, 2024
Visit Reason
The inspection was conducted as a partial, unannounced visit due to a complaint and incident review of the facility.
Findings
The inspection identified multiple deficiencies including a medication error resulting in a resident's death, inadequate staffing to meet resident needs especially during emergencies, failure to conduct monthly fire drills, outdated fire safety inspections, delayed evacuation times during fire drills, medication administration by uncertified staff, incomplete medication records, and incomplete or outdated resident assessments and support plans.
Complaint Details
The inspection was complaint-related and included an incident involving a medication error resulting in a resident's death. The medication error was self-reported and investigated, with the neglect allegation found to be unfounded.
Deficiencies (12)
| Description |
|---|
| Resident #9 was administered incorrect medication dosage leading to death. |
| Inadequate staffing on 3rd shift to meet resident needs and emergency evacuation requirements. |
| Resident #1 not always alerted by fire alarm flashers due to hearing impairment. |
| Failure to conduct unannounced monthly fire drills in April 2023 and January 2024. |
| No fire safety inspection completed since 9/16/22. |
| Evacuation times exceeded state-issued evacuation time during multiple fire drills. |
| Staff Person A administered medications without certification. |
| Medication records incomplete for multiple residents, including failure to document administration and updated medication concentrations. |
| Failure to follow prescriber's orders for Resident #9 medication administration. |
| Resident #5 and #6 had out-of-date assessments and support plans (RASPs). |
| Resident #7's support plan did not document hospice services. |
| Resident #8's support plan lacked signature or indication of refusal/inability to sign. |
Report Facts
Residents served: 41
License capacity: 75
Immobile residents: 21
Staff on 3rd shift: 2
Staff hours on 3rd shift: 28
Fire drill missed: 2
Fire safety inspection last date: Sep 16, 2022
Evacuation times exceeded: 11
Inspection Report
Complaint Investigation
Census: 45
Capacity: 75
Deficiencies: 0
Oct 12, 2023
Visit Reason
The inspection was conducted as a complaint investigation at the facility on 10/12/2023.
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 regulatory citations were found.
Report Facts
Residents Served: 45
License Capacity: 75
Current Hospice Residents: 4
Residents Age 60 or Older: 45
Residents with Mobility Need: 6
Inspection Report
Complaint Investigation
Census: 51
Capacity: 75
Deficiencies: 2
Jun 9, 2023
Visit Reason
The inspection was conducted as a complaint and incident review of the facility on 06/09/2023 and 06/12/2023 to determine compliance with regulations.
Findings
The facility was found to have deficiencies related to support plan documentation, including failure to update a resident's support plan to reflect 1 to 1 staff observation and missing dates on resident signatures in support plans. The submitted plan of correction was accepted and implemented.
Complaint Details
The inspection was complaint-related with the reason stated as Complaint, Incident. The submitted plan of correction was accepted and implemented with follow-up audits planned.
Deficiencies (2)
| Description |
|---|
| Resident #1's Resident Assessment and Support Plan was not updated to indicate placement on 1 to 1 staff observation and lacked clarity on observation frequency. |
| Resident #2's support plan was signed by the resident but the date of signature was missing, making it unclear when the resident participated in the assessment process. |
Report Facts
License Capacity: 75
Residents Served: 51
Current Hospice Residents: 5
Resident Support Staff: 51
Total Daily Staff: 108
Waking Staff: 81
Residents Age 60 or Older: 51
Residents with Mobility Need: 6
Inspection Report
Renewal
Census: 57
Capacity: 75
Deficiencies: 14
May 2, 2023
Visit Reason
The inspection was conducted as a renewal and incident review of the facility to determine compliance with licensing regulations and to verify the submitted plan of correction was fully implemented.
Findings
The inspection identified multiple deficiencies including failure to post the current license inspection summary, expired batteries in carbon monoxide monitors, inadequate staffing on 3rd shift, incomplete first aid/CPR training coverage, incomplete direct care staff training, improper labeling of leftover food, missed fire drills and incomplete fire drill records, medication administration and documentation errors, and incomplete resident support plans. Plans of correction were accepted and implemented with ongoing audits scheduled to ensure sustained compliance.
Deficiencies (14)
| Description |
|---|
| The home did not have the License Inspection Summary (LIS) report dated 7/6/22 posted in the home as required. |
| The batteries in the carbon monoxide monitor located in the hallway near the gas fired water heaters were due to be replaced in December 2022. |
| The home does not have adequate staff scheduled on 3rd shift to meet the needs of the residents in the event of an emergency. |
| Only one staff person with first aid and CPR training was present on 3rd shift while the census was 57 residents. |
| A direct care staff person did not take the required department direct care competency test until after hire. |
| Unlabeled and undated leftover meat was found in the freezer and cooler. |
| The home did not conduct fire drills in December 2022 and January 2023. |
| Fire drill logs were incomplete as they did not record the number of residents present or the exit routes used. |
| Medication technicians had annual practicums completed more than 12 months apart. |
| Pharmacy label on Olanzapine medication did not match the physician's order. |
| Resident's prescribed medication was not available in the medication cart to be administered as needed. |
| Medication administration records lacked documentation of medication administration for multiple residents on various dates. |
| Resident support plan was incomplete as bladder and bowel management sections were not completed. |
| Resident support plan was not updated to reflect the ordered pureed diet. |
Report Facts
License Capacity: 75
Residents Served: 57
Current Residents with Mobility Needs: 14
Current Residents Age 60 or Older: 57
Current Residents with Physical Disability: 1
Staff on 3rd Shift: 2
Total Daily Staff: 71
Waking Staff: 53
Inspection Report
Complaint Investigation
Census: 56
Capacity: 75
Deficiencies: 7
Mar 28, 2023
Visit Reason
The inspection was conducted as a partial, unannounced visit due to a complaint and incident review at the facility on 03/28/2023.
Findings
The inspection identified multiple deficiencies including staff sleeping on duty, outdated medical evaluations for residents, medication storage and administration issues, failure to notify prescribers of medication refusals, and incomplete resident support plans related to falls and cognitive needs. Plans of correction were accepted and implemented with ongoing audits and education scheduled.
Complaint Details
The inspection was triggered by a complaint and incident, as noted under Inspection Information on page 2.
Deficiencies (7)
| Description |
|---|
| Staff member admitted to sleeping during working hours despite requirement that all direct care staff be awake when residents are present. |
| Residents #2 and #3 had medical evaluations completed more than 60 days prior to admission, not meeting regulatory timeframe. |
| Resident #2's initial medical evaluation indicated needs not met by the home, including secured dementia care unit requirements. |
| Resident #1's prescribed medication was not available on site on the inspection date. |
| Resident #1 refused medication but the home did not notify the prescriber within required timeframe. |
| Resident #1 was prescribed medication that was not administered as prescribed on multiple occasions. |
| Resident #1 had multiple falls with no documented assessment or support plan to prevent future falls; Resident #2's assessment lacked documentation of level of care and behavioral needs. |
Report Facts
Residents present: 56
Licensed capacity: 75
Staffing hours: 69
Waking staff: 52
Residents with supplemental security income: 0
Residents age 60 or older: 56
Residents with mobility needs: 13
Residents in hospice: 6
Resident #1 falls: 4
Inspection Report
Follow-Up
Census: 57
Capacity: 75
Deficiencies: 8
Jan 11, 2023
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident at the facility.
Findings
The report details multiple violations related to resident abuse reporting, staff supervision, medical evaluations, use of restraints, support plan documentation, and record content. The facility submitted a plan of correction which was accepted and implemented by March 9, 2023.
Complaint Details
The visit was triggered by an incident, indicating a complaint-related reason. Specific substantiation status is not stated.
Deficiencies (8)
| Description |
|---|
| Failure to immediately report suspected abuse of residents to the local area agency on aging and the Department of Human Services. |
| Failure to immediately suspend or implement a plan of supervision for a staff person involved in an abuse allegation. |
| Direct care staff person hired without a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Residents did not have medical evaluations completed within required timeframes or with all required information. |
| Use of mechanical restraint (gait belt used to restrain resident to a chair) prohibited by regulation. |
| Resident Assessment and Support Plans (RASPs) not updated to reflect supervision needs, incidents, or resident behaviors. |
| Resident Assessment and Support Plans not signed by residents without indication of refusal. |
| Resident record photo not updated within the last two years. |
Report Facts
License Capacity: 75
Residents Served: 57
Current Hospice Residents: 4
Total Daily Staff: 68
Waking Staff: 51
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 11
Residents 60 Years or Older: 57
Residents with Physical Disability: 1
Inspection Report
Renewal
Census: 61
Capacity: 75
Deficiencies: 12
Jul 6, 2022
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 07/06/2022 and 07/07/2022 to review compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies related to quality management plan content, staff training, fire safety orientation, medication management including storage, labeling, documentation, and adherence to prescriber's orders. Plans of correction were accepted and implemented by 02/28/2023.
Deficiencies (12)
| Description |
|---|
| Quality management plan did not address staff training and complaint procedures. |
| Insufficient number of staff certified in First Aid and CPR present at all times. |
| Agency staff member did not receive first day general fire safety orientation. |
| Agency staff member did not receive training in resident rights, Older Adult Protective Services Act, emergency medical plan, and reporting within first 40 hours. |
| The home did not conduct a fire drill in May and June 2022. |
| Medications removed from original labeled containers when residents leave the facility. |
| Original medication containers lacked proper labeling with prescribed dosage and instructions. |
| PRN medications for multiple residents were not available. |
| Verbal order for medication change not followed by written order within 48 hours. |
| Medication record missing diagnosis or purpose for medication including PRN. |
| Prescriber was not notified of resident's medication refusal within required timeframe. |
| Medications withheld without a valid hold order; failure to take required resident weights for PRN medication. |
Report Facts
Residents served: 61
License capacity: 75
Staff certified in First Aid/CPR required: 2
Staff certified in First Aid/CPR present: 1
Fire drills missed: 2
PRN medications unavailable: 5
Inspection Report
Plan of Correction
Census: 58
Capacity: 75
Deficiencies: 1
Dec 21, 2021
Visit Reason
The inspection was conducted as a complaint investigation with a partial, unannounced visit on 12/21/2021 to review compliance and follow up on a plan of correction submission.
Findings
The facility was found to have a deficiency related to the support plan for Resident #1, which was not updated to reflect frequent incontinence checks, staff assistance with brief changes, and use of a wander guard. The plan of correction was submitted and fully implemented by 02/28/2022.
Complaint Details
The visit was complaint-related and included a follow-up on the plan of correction. The submitted plan of correction was determined to be fully implemented as of 02/28/2022.
Deficiencies (1)
| Description |
|---|
| Resident #1's support plan was not updated to reflect frequent incontinence checks, staff assistance with brief changes, and use of a wander guard for exit seeking behaviors. |
Report Facts
License Capacity: 75
Residents Served: 58
Current Residents in Hospice: 3
Total Daily Staff: 60
Waking Staff: 45
Residents with Mobility Need: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michele Moskalczyk | Human Services Licensing Supervisor | Signed the letter confirming full implementation of the plan of correction |
| Care Services Manager | Updated Resident #1's support plan and involved in auditing support plans | |
| Executive Director | Educated Care Services Manager on regulatory requirements and involved in auditing support plans |
Inspection Report
Follow-Up
Census: 45
Capacity: 75
Deficiencies: 1
May 11, 2021
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 05/11/2021 to review the implementation of a previously submitted plan of correction related to an incident.
Findings
The submitted plan of correction was determined to be fully implemented with continued compliance required. The deficiency involved a staff member not treating a resident with dignity and respect, which was addressed through staff re-education and ongoing resident interviews to monitor compliance.
Deficiencies (1)
| Description |
|---|
| Staff person A did not treat resident #1 with dignity and respect, telling the resident 'you're not leaving here ever'. |
Report Facts
License Capacity: 75
Residents Served: 45
Current Hospice Residents: 1
Residents Age 60 or Older: 45
Residents with Mobility Need: 3
Residents with Physical Disability: 1
Total Daily Staff: 48
Waking Staff: 36
Notice
Capacity: 75
Deficiencies: 0
Apr 30, 2021
Visit Reason
The document serves as a renewal notification for the operation of Maidencreek Place Personal Care Home and informs that an onsite inspection will be conducted within the next twelve months as required by state regulations.
Findings
No inspection findings are reported in this document; it is a license renewal letter and certificate of compliance confirming the facility's authorized capacity and licensing status.
Report Facts
Maximum licensed capacity: 75
Inspection Report
Renewal
Census: 44
Capacity: 75
Deficiencies: 3
Mar 30, 2021
Visit Reason
The inspection was conducted as a renewal and complaint investigation of the facility Maidencreek Place on 03/30/2021 and 03/31/2021 to assess compliance with licensing requirements.
Findings
The inspection identified deficiencies including lack of thermometers in refrigerators/freezers, failure to post menus one week in advance, and inaccuracies in residents' medication self-administration documentation. Plans of correction were accepted and implemented with ongoing monitoring.
Deficiencies (3)
| Description |
|---|
| The home's refrigerator in the activity/dining room area did not have a thermometer in the refrigerator and freezer compartments. |
| The home did not have the next week's menus posted in a public and conspicuous space; only the current week's menu was posted. |
| Resident #1 and Resident #2's Resident Assessment and Support Plans (RASP) inaccurately documented their ability to self-administer medications. |
Report Facts
License Capacity: 75
Residents Served: 44
Resident Support Staff: 0
Total Daily Staff: 44
Waking Staff: 33
Hospice Current Residents: 1
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