Inspection Report
Follow-Up
Census: 25
Capacity: 72
Deficiencies: 2
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.
Deficiencies (2)
| Description |
|---|
| 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
License Capacity: 72
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
Renewal
Census: 27
Capacity: 72
Deficiencies: 10
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.
Deficiencies (10)
| Description |
|---|
| 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
License Capacity: 72
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
Census: 30
Capacity: 72
Deficiencies: 0
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
Resident Census: 30
Total Licensed Capacity: 72
Current Hospice Residents: 3
Residents Age 60 or Older: 30
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 5
Inspection Report
Complaint Investigation
Census: 32
Capacity: 32
Deficiencies: 6
Oct 19, 2023
Visit Reason
The inspection was a complaint investigation conducted due to a complaint received regarding resident care and facility compliance.
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.
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.
Deficiencies (6)
| Description |
|---|
| 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
Capacity: 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
Complaint Investigation
Census: 38
Capacity: 72
Deficiencies: 2
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.
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.
Complaint Details
The visit was complaint-related, investigating medication discrepancies and errors. The submitted plan of correction was determined to be fully implemented.
Deficiencies (2)
| Description |
|---|
| 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
License Capacity: 72
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
Follow-Up
Census: 47
Capacity: 72
Deficiencies: 3
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.
Deficiencies (3)
| Description |
|---|
| 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
License capacity: 72
Current hospice residents: 4
Residents diagnosed with mental illness: 5
Residents with mobility need: 21
Residents 60 years or older: 47
Inspection Report
Renewal
Census: 41
Capacity: 72
Deficiencies: 7
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.
Deficiencies (7)
| Description |
|---|
| 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
License Capacity: 72
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
Follow-Up
Census: 47
Capacity: 72
Deficiencies: 4
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.
Deficiencies (4)
| Description |
|---|
| 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
License Capacity: 72
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
Follow-Up
Census: 44
Capacity: 72
Deficiencies: 6
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.
Deficiencies (6)
| Description |
|---|
| 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
License Capacity: 72
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
Plan of Correction
Deficiencies: 0
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
Complaint Investigation
Census: 37
Capacity: 72
Deficiencies: 7
Feb 18, 2022
Visit Reason
The inspection was conducted as a complaint and incident investigation to review compliance with resident care and safety regulations.
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.
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.
Deficiencies (7)
| Description |
|---|
| 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
License Capacity: 72
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
Renewal
Census: 41
Capacity: 72
Deficiencies: 4
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.
Deficiencies (4)
| Description |
|---|
| 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
License Capacity: 72
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
Monitoring
Census: 35
Capacity: 72
Deficiencies: 1
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.
Deficiencies (1)
| Description |
|---|
| Failure to provide proof of refund to the estate of a deceased resident within the required timeframe. |
Report Facts
License Capacity: 72
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. |
Notice
Capacity: 72
Deficiencies: 0
Oct 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
Total licensed capacity: 72
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notice letter. |
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