Inspection Reports for
Celebration Villa of Loyalsock
2985 4 Mile Dr, Montoursville, PA 17754, Montoursville, PA, 17754
Back to Facility Profile20 Reports
Inspection Report — Jun 9, 2026
Date: Jun 9, 2026
Visit Reason
The inspection was a partial, unannounced licensing inspection conducted due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
Residents Served: 47
Current Hospice Residents: 3
Residents Age 60 or Older: 47
Residents with Mobility Need: 15
Inspection Report — Jun 2, 2026
Date: Jun 2, 2026
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
Residents Served: 46
Current Hospice Residents: 3
Resident Support Staff: 0
Total Daily Staff: 60
Waking Staff: 45
Inspection Report — Sep 10, 2025
Renewal
Date: Sep 10, 2025
Visit Reason
The inspection was conducted as a renewal visit to evaluate compliance with licensing requirements for Celebration Villa of Loyalsock.
Findings
The submitted plan of correction was found to be fully implemented. Two deficiencies were identified related to medication documentation errors and failure to follow prescriber's orders, both of which have corrective actions and ongoing monitoring in place.
Citations (2)
Resident #1's blood glucose reading was incorrectly recorded on the medication administration record.
Resident #2's heart rate was not measured prior to administering medication as ordered.
Report Facts
Residents Served: 44
Current Hospice Residents: 3
Residents with Mental Illness: 1
Residents with Mobility Need: 8
Residents with Physical Disability: 1
Total Daily Staff: 52
Waking Staff: 39
Inspection Report — Oct 24, 2024
Renewal
Date: Oct 24, 2024
Visit Reason
The inspection was conducted as a renewal review of the facility's compliance with licensing regulations.
Findings
The submitted plan of correction was found to be fully implemented. Deficiencies included lack of operable lamps at bedside, incomplete medical evaluations, and premature resident assessments, all of which were addressed with corrective actions and staff training.
Citations (3)
Residents in rooms 13 and 120 did not have an operable lamp or other source of lighting that could be turned on at bedside.
Resident #1's most recent Documentation of Medical Evaluation was not signed by a physician.
Resident #2's assessment portion of the Resident Assessment and Support Plan was completed prior to the date of admission.
Report Facts
Residents Served: 48
Current Hospice Residents: 3
Total Daily Staff: 51
Waking Staff: 38
Notice — Sep 13, 2024
Date: Sep 13, 2024
Visit Reason
The document is a response to a request for a waiver of Pennsylvania Code § 2600.190(b) to allow unlicensed direct care staff to administer subcutaneous injections of GLP-1 agonist medications in a personal care home.
Findings
The waiver outlines training requirements for direct care staff administering GLP-1 agonist injections, including completion of a Department-approved medication administration course, in-person training by licensed health care professionals, and annual training hours. It also mandates policies for monitoring, documentation, and availability of clinical contacts.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Notice — Mar 25, 2024
Date: Mar 25, 2024
Visit Reason
Response to a facility request to use the TruLoo Smart Toilet seat to automate tracking of bowel movements and urinations for clinical monitoring.
Findings
The Department reviewed the submitted information and determined that the informed consent process meets regulatory requirements for resident rights and privacy. The letter does not endorse the device but confirms compliance with privacy regulations if procedures are maintained.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Director, Bureau of Human Services Licensing | Signed the letter responding to the facility's request. |
Inspection Report — Sep 29, 2022
Date: Sep 29, 2022
Visit Reason
The inspection was conducted as a partial, unannounced licensing inspection due to an incident.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Resident Support Staff: 9
Total Daily Staff: 64
Waking Staff: 48
Residents Served: 46
Current Hospice Residents: 1
Residents Age 60 or Older: 46
Residents with Mobility Need: 9
Inspection Report — Jun 22, 2022
Renewal
Date: Jun 22, 2022
Visit Reason
The inspection was conducted as a renewal visit for the facility license.
Findings
The inspection identified deficiencies related to refrigerator/freezer temperatures exceeding required limits, fire drills being conducted on a predictable schedule, and incomplete resident record content regarding identifiable marks. Plans of correction were accepted and implemented with training and ongoing monitoring.
Citations (3)
Refrigerators had temperature readings above 40°F, including the main kitchen Kalok refrigerator at 45°F, a small Continental refrigerator at 50°F, and a med room refrigerator at 46°F.
Fire drills were consistently conducted at the end of each month, indicating a pattern rather than varying days and times as required.
Resident records did not indicate if residents had any identifiable marks.
Report Facts
Residents Served: 39
Staffing Hours: 58
Waking Staff: 44
Hospice Residents: 1
Residents with Mobility Need: 19
Fire Drill Dates: 6
Inspection Report — May 24, 2022
Complaint Investigation
Date: May 24, 2022
Visit Reason
The inspection was conducted as a complaint and incident investigation with an unannounced partial inspection on 05/24/2022 and an exit conference on 06/06/2022.
Complaint Details
The visit was complaint-related, investigating medication administration errors involving two residents and multiple staff members. The plan of correction was accepted and fully implemented.
Findings
The inspection found medication administration errors where Resident 1's medications were given to Resident 2 in error on two occasions. Staff members involved were counseled and re-educated, and ongoing monitoring and training were implemented to prevent recurrence.
Citations (1)
Resident 1’s prescription of Tramadol was given to Resident 2 in error by Staff Member A on 4/9/2022, and Resident 1’s prescribed medication of Hydracodone was given to Resident 2 in error by Staff Member B on 4/13/2022. Pill cups with pills still in them were found in resident rooms on several occasions.
Report Facts
Residents Served: 36
Current Hospice Residents: 1
Residents 60 Years or Older: 36
Residents with Mobility Need: 9
Inspection Report — Jan 11, 2022
Renewal
Date: Jan 11, 2022
Visit Reason
The inspection was conducted as part of the Pennsylvania Department of Human Services, Bureau of Human Service Licensing licensing inspections on 01/11/2022 and 01/13/2022 for the facility Celebration Villa of Loyalsock.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report — Jun 29, 2021
Renewal
Date: Jun 29, 2021
Visit Reason
The inspection was a renewal visit conducted on 06/29/2021 and 06/30/2021 to review compliance with licensing requirements at Elmcroft of Loyalsock.
Findings
The inspection identified multiple deficiencies including outdated carbon monoxide detector batteries, incomplete staff fire safety orientation, outdated food storage, missing documentation of emergency procedure submission, incomplete medical evaluation forms for residents, and unsigned resident support plans. Plans of correction were accepted and documented as implemented with staff training completed.
Citations (9)
Batteries in the carbon dioxide monitor in the lobby were last changed in February 2020 and must be replaced annually.
Staff person A was not trained in required fire safety and emergency preparedness topics on their first day of work.
Staff person B did not receive training on resident rights for the training year 2019; Staff person C did not receive fire safety training by a fire safety expert for 2019.
Four large dented cans (3 spaghetti sauce, 1 stewed tomatoes) were stored in the pantry and must not be used.
Emergency procedures were not documented as reviewed and submitted to the local emergency management agency in 2020 or 2021.
During a fire drill on 12/20/2019, one resident refused to leave their room.
Documentation of Medical Evaluation (DME) form for resident #1 was missing pulse rate; DME form for resident #2 was missing weight.
Support plan for resident #3 was not finalized within 30 days of admission.
Support plan for resident #1 was not signed by the resident or the person who completed the assessment.
Report Facts
Residents Served: 32
Dented Cans: 4
Staffing Hours: 42
Waking Staff: 32
Current Hospice Residents: 1
Residents with Mobility Need: 10
Residents 60 Years or Older: 32
Residents Diagnosed with Mental Illness: 1
Inspection Report — Mar 30, 2021
Renewal
Date: Mar 30, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 03/30/2021 and 03/31/2021 for the facility.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report — Dec 21, 2020
Follow-Up
Date: Dec 21, 2020
Visit Reason
The visit was a follow-up inspection to verify the implementation of a previously submitted plan of correction for the facility.
Findings
The submitted plan of correction was found to be fully implemented. The facility demonstrated compliance with medical evaluation and support plan documentation requirements.
Citations (2)
141a Medical Evaluation Information: The medical evaluation form dated 1/21/20 for resident #1 was missing height, temperature, body positioning, and mobility needs.
227d Support Plan Medical/Dental: The support plan dated 11/28/20 was not updated to reflect the resident's need for a female staff person for showering assistance and did not address cognitive needs related to a reported incident.
Report Facts
Residents Served: 37
Current Hospice Residents: 2
Inspection Report — Nov 23, 2020
Routine
Date: Nov 23, 2020
Visit Reason
The inspection was a licensing inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Notice — Sep 10, 2020
Date: Sep 10, 2020
Visit Reason
The document serves to grant a waiver for the requirement that a personal care home administrator complete a Department-approved orientation program due to its current unavailability.
Findings
The waiver is granted with conditions including that the administrator must attend the orientation within 15 days of its availability and that documentation of training and qualifications be maintained and available upon request.
Notice — May 5, 2020
Date: May 5, 2020
Visit Reason
This document serves as a renewal notification and certificate of compliance for the Personal Care Home 'Elmcroft of Loyalsock' following receipt of the renewal application dated March 24, 2020.
Findings
A regular license is issued in response to the renewal application. The Department will conduct an onsite inspection within the next twelve months to ensure compliance with applicable regulations.
Inspection Report — Mar 25, 2020
Complaint Investigation
Date: Mar 25, 2020
Visit Reason
The inspection was conducted as a complaint investigation and incident review at Elmcroft of Loyalsock.
Complaint Details
The inspection was triggered by a complaint and incident. The violation involved medication administration error. The plan of correction was approved and implemented as of 5-26-20.
Findings
A violation was found where a staff member mistakenly administered another resident's medication to resident #1 on 1/29/2020. The submitted plan of correction was fully implemented and approved.
Citations (1)
On 1/29/2020, staff person A mistakenly administered another resident's medications to resident #1.
Report Facts
Residents Served: 38
Current Hospice Residents: 1
Resident Support Staff: 0
Total Daily Staff: 44
Waking Staff: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cassie Cain | Administrator | Named as Administrator and Legal Entity Representative signing plan of correction |
Inspection Report — Jun 4, 2019
Renewal
Date: Jun 4, 2019
Visit Reason
The inspection was a renewal inspection conducted by the Department’s Bureau of Human Services Licensing to assess compliance with 55 Pa. Code Chapter 2600 for Personal Care Homes.
Findings
The inspection found violations related to resident privacy, outdated durable medical equipment (DME), missing posted menus, medication technician training deficiencies, insulin administration errors, and incomplete resident assessment and support plans. Plans of correction were submitted addressing each violation with partial implementation progress noted.
Citations (6)
Privacy coding documents exposing resident confidential information were found posted in the home's entrance way during prior inspections.
Resident #1 had out-of-date durable medical equipment which was updated after discovery; staff were re-educated on DME tracking and scheduling.
Menus were not posted as required; Dining Services staff were retrained and a process was implemented to ensure weekly menu posting compliance.
Medication Technician A did not receive annual medication administration training by the due date due to maternity leave but was retrained and re-certified in June 2019.
Medication administration errors occurred with insulin dosing; all Medication Technicians were retrained on proper procedures and documentation.
Resident #3's assessment and support plan portions of the RASP were not completed timely, with delays up to 15 days; staff were retrained on the RASP process.
Report Facts
Residents Served: 41
Total Daily Staff: 44
Waking Staff: 33
Residents Diagnosed with Mental Illness: 7
Residents Diagnosed with Intellectual Disability: 7
Residents with Mobility Need: 3
Residents with Physical Disability: 1
Residents Age 60 or Older: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sara Finkbiner | Executive Director | Named in multiple plans of correction as responsible for oversight and training. |
Notice — Mar 28, 2019
Date: Mar 28, 2019
Visit Reason
This document serves as a renewal notification for the Personal Care Home license of Elmcroft of Loyalsock, confirming the renewal application received and the issuance of a regular license.
Findings
The Department advises that an onsite annual inspection will be conducted within the next twelve months to ensure compliance with applicable laws and regulations. No inspection findings are reported in this document.
Report Facts
Inspection Report — Jun 7, 2018
Original Licensing
Date: Jun 7, 2018
Visit Reason
The inspection was conducted as a licensing inspection for a new legal entity operating a Personal Care Home.
Findings
The facility was found to be in substantial compliance with applicable regulations, but the licensing inspector was unable to complete a full inspection due to the newness of the legal entity.
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