Inspection Reports for
Celebration Villa of Nittany Valley

150 Farmstead Ln, State College, PA 16803, State College, PA, 16803

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39 Reports

2018–2026

Inspection Report — Feb 5, 2026

Complaint Investigation
Date: Feb 5, 2026

Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 02/05/2026 and 02/06/2026 to review compliance and the submitted plan of correction.

Complaint Details
The inspection was complaint-driven as indicated by the inspection information on page 2, with a partial unannounced visit on 02/05/2026 and 02/06/2026.
Findings
The facility had multiple deficiencies related to failure to report incidents timely, inoperable fire suppression and smoke detection systems, inadequate fire watch procedures, inaccurate fire drill documentation, and evacuation procedure issues. The submitted plan of correction was accepted and later fully implemented.

Citations (4)
Regulation 2600.16c: The facility failed to report the inoperable sprinkler system and a power outage to the Department within 24 hours as required.
Regulation 2600.130h: The facility did not initiate a fire watch immediately when the sprinkler system was out of service, delaying until codes enforcement required it.
Regulation 2600.132c: Fire drill records lacked evacuation times and contained inaccurate documentation of drill dates and times.
Regulation 2600.132d: The facility failed to report modifications to the fire protection system to the Fire Safety Expert, invalidating the evacuation time calculation during a power outage.
Report Facts
Residents Served: 50 Secured Dementia Care Unit Residents Served: 16 Hospice Current Residents: 6 Residents Age 60 or Older: 50 Residents with Mobility Need: 25

Employees mentioned
NameTitleContext
Christian CummingsHuman Services Licensing SupervisorSigned the licensing inspection summary letter
Unnamed Interim Executive DirectorInterim Executive DirectorProvided training and implemented corrective actions related to deficiencies
Unnamed Director of NursingDirector of NursingReceived training related to incident reporting and fire safety regulations
Unnamed Maintenance DirectorMaintenance DirectorReceived training and responsible for fire watch and fire drill documentation

Inspection Report — Oct 8, 2025

Follow-Up
Date: Oct 8, 2025

Visit Reason
The visit was conducted as a follow-up to review the submitted plan of correction for compliance with medical evaluation requirements.

Findings
The submitted plan of correction was determined to be fully implemented. The facility demonstrated compliance with Regulation 2600.141.a regarding timely medical evaluations for residents.

Citations (1)
Resident medical evaluation was not completed within 60 days prior to their admission.
Report Facts
Residents Served: 53 Secured Dementia Care Unit Residents Served: 17 Hospice Current Residents: 9 Residents Age 60 or Older: 54 Residents with Mobility Need: 21

Employees mentioned
NameTitleContext
Executive DirectorNamed in plan of correction actions and ongoing audits related to medical evaluation compliance.
Director of NursingNamed in plan of correction actions and ongoing audits related to medical evaluation compliance.
Regional Director of Clinical OperationsProvided training on Regulation 2600.141.a.
Director of Sales and MarketingReceived training on Regulation 2600.141.a.

Inspection Report — Jul 30, 2025

Renewal
Date: Jul 30, 2025

Visit Reason
The inspection was conducted as a renewal and complaint investigation to assess compliance with licensing regulations and to review the submitted plan of correction.

Complaint Details
The inspection included a complaint investigation component, but the substantiation status is not explicitly stated in the report.
Findings
The inspection identified multiple deficiencies including issues with resident record confidentiality, contract signatures, refunds, staff training, resident personal equipment safety, poisonous materials storage, infestation, cleanliness and maintenance, dietary needs, medication management, resident rights education, and documentation completeness. The facility submitted plans of correction for all deficiencies, which were accepted and implemented by the dates noted.

Citations (23)
Resident care logs and binders with resident information were left unsecured and medication room door was open exposing resident information.
Resident-home contract for resident #2 was not signed by the resident.
Resident #1 did not receive the full refund owed after discharge.
Staff members did not receive required fire safety training for the 2024 year.
The home did not have a staff training plan for the 2025 training year.
Oxygen tanks were unsecured and stored directly on the floor in resident rooms.
A cleaning bottle was mislabeled with a crossed out label and handwritten text.
Poisonous materials were unlocked and accessible to residents in the secure dementia unit.
An active hornet's nest was found above the therapy patio exit door.
Laundry room washer/dryer outlet was pulled away from the wall exposing electrical wires.
No toilet paper was available in the activities room shared bathroom.
A large tube of hamburger meat was not labeled or dated in the freezer.
Expired vanilla pudding snack packs were found in a cabinet.
Emergency drinking water supply was below the required amount for the number of residents.
Resident #5's medical evaluation did not indicate ability to self-administer medications.
Resident #2 was on a mechanically soft diet without a doctor's order.
Discontinued medication Diphen/Atrop 2.5 mg was still in the medication cart for Resident #6.
Resident #7 was administered medication despite systolic blood pressure readings above prescribed parameters.
Resident #2 was not educated on the right to refuse medication if a medication error is suspected.
Resident #1's initial assessment was not completed within 15 days of admission.
Resident #2's support plan was not signed by the resident or documented as refused.
Directions for operating key-locking devices at Memory Care courtyard fence exit were illegible.
Resident #5's record did not include hair color, eye color, or identifiable marks.
Report Facts
Residents Served: 37 Secured Dementia Care Unit Residents Served: 17 Hospice Residents: 8 Residents 60 Years or Older: 54 Residents with Mobility Need: 21 Staffing Hours - Resident Support Staff: 41 Staffing Hours - Total Daily Staff: 99 Staffing Hours - Waking Staff: 74 Refund Amount Owed: 8382.01 Refund Amount Paid: 496.78 Emergency Drinking Water on Hand (gallons): 150 Emergency Drinking Water Required (gallons): 177

Inspection Report — Apr 9, 2025

Follow-Up
Date: Apr 9, 2025

Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident at the facility.

Findings
The submitted plan of correction was fully implemented and compliance was maintained. The report details an abuse incident where a resident was pushed, resulting in a fractured femur, and outlines corrective actions including assessments, monitoring, staff education, and ongoing quality assurance.

Citations (1)
A resident was pushed by another resident resulting in a fall and fractured right femur, violating abuse prevention regulations.
Report Facts
Residents Served: 49 Secured Dementia Care Unit Residents Served: 15 Hospice Current Residents: 11 Residents Age 60 or Older: 49 Residents with Mobility Need: 17

Employees mentioned
NameTitleContext
Executive DirectorEducated on Regulation 2600.42.b. by Regional Director of Clinical Operations and involved in monitoring and reviewing support plans
Director of NursingNotified Medical Director of incident, educated floor staff on regulation, involved in medication reconciliation and monitoring support plans
Medical DirectorNotified of incident and conducted further evaluation of resident

Inspection Report — Feb 5, 2025

Follow-Up
Date: Feb 5, 2025

Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident to verify the submitted plan of correction was fully implemented.

Findings
The facility was found to have corrected previous deficiencies related to incomplete medical evaluations and unsigned resident support plans. Compliance was confirmed with ongoing training and auditing procedures implemented.

Citations (2)
Resident Medical Evaluation dated does not have the health status or cognition section completed.
Resident Assessment and Support Plan dated is not signed by the assessor.
Report Facts
Residents Served: 50 Secured Dementia Care Unit Residents Served: 15 Hospice Current Residents: 9 Residents Age 60 or Older: 50 Residents with Mobility Need: 23 Total Daily Staff: 73 Waking Staff: 55

Notice — Nov 12, 2024

Date: Nov 12, 2024

Visit Reason
The document serves as a response to a facility's 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.

Findings
The waiver outlines training requirements for direct care staff administering GLP-1 agonist injections, including completion of Department-approved courses, in-person training by licensed professionals, and annual training hours. It also mandates policies for monitoring, documentation, and availability of a clinical contact.

Report Facts
Annual training hours required: 4 License number: 233740

Employees mentioned
NameTitleContext
Theresa HartmanBureau Director, Human Services LicensingSigned the waiver approval letter.

Inspection Report — Sep 10, 2024

Renewal
Date: Sep 10, 2024

Visit Reason
The inspection was conducted as a renewal and incident review of the facility on 09/10/2024.

Findings
The inspection identified multiple deficiencies including lack of a written policy on voice-controlled electronic devices, incomplete direct care staff training documentation, unlabeled leftover food items, incomplete fire drill records, medication administration errors, and outdated resident support plans. Plans of correction were accepted and implemented with ongoing monitoring.

Citations (7)
The home does not have a written policy regarding the use of voice-controlled electronic devices.
Staff member C was hired without documentation of completion of the Department-approved direct care training course.
No documentation that Staff Member A had training on Resident Rights or The Older Adult Protective Services Act during the 2023 training year.
There were 2 unlabeled bags of tater tots, 1 unlabeled bag of French fries, and 1 unlabeled bag of sweet potato fries in the standalone freezer outside of the kitchen.
The fire drill log for August 2024 did not list the number of residents in the home at the time of the fire drill and only listed the number of residents evacuated.
Resident #1 was administered an incorrect amount of insulin not consistent with the sliding scale order based on blood sugar reading.
Resident #2's most recent Resident Assessment Support Plan was not revised within one year as required.
Report Facts
Residents Served: 43 Secured Dementia Care Unit Residents Served: 15 Hospice Current Residents: 7 Residents Age 60 or Older: 43 Residents with Mobility Need: 25

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 to identify clinically concerning changes.

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
NameTitleContext
Theresa HartmanDirector, Bureau of Human Services LicensingSigned the letter responding to the facility's request.

Inspection Report — Jan 30, 2024

Date: Jan 30, 2024

Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident.

Findings
No regulatory citations or deficiencies were identified during this inspection.

Report Facts
Residents Served: 33 Residents Served in Secured Dementia Care Unit: 15 Total Daily Staff: 54 Waking Staff: 41 Residents with Mobility Need: 21 Residents 60 Years or Older: 33

Inspection Report — Nov 27, 2023

Complaint Investigation
Date: Nov 27, 2023

Visit Reason
The inspection was conducted as a complaint and incident investigation with an unannounced partial review on 11/27/2023 and an exit conference on 12/04/2023.

Complaint Details
The visit was complaint-related with a follow-up type of Plan of Correction (POC) submission. The plan of correction was accepted and fully implemented by 01/09/2024.
Findings
The submitted plan of correction was determined to be fully implemented. A deficiency was noted regarding a resident's assessment and support plan lacking a signature or notation of refusal to sign.

Citations (1)
Resident #1's Resident Assessment and Support Plan did not include a signature, a refusal to sign, or an indication of the ability to sign.
Report Facts
Residents Served: 41 Residents Served in Dementia Unit: 17 Resident Mobility Need: 18 Total Daily Staff: 59 Waking Staff: 44

Employees mentioned
NameTitleContext
Regional Director of OperationsCompleted new Resident Assessment and Support Plan for Resident #1 on 11/28/2023.
Executive DirectorTrained Director of Nursing and Assistant Director of Nursing on Regulation 227h on 12/20/2023 and responsible for ongoing monitoring.
Director of NursingTrained on Regulation 227h and involved in ongoing monitoring of Resident Assessments and Support Plans.
Assistant Director of NursingTrained on Regulation 227h and involved in ongoing monitoring of Resident Assessments and Support Plans.

Inspection Report — Sep 13, 2023

Renewal
Date: Sep 13, 2023

Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.

Findings
The inspection found multiple deficiencies including missing resident signatures on contracts and rights forms, incomplete staff training, lack of bedside lighting in one room, outdated food labeling, missed fire drills and evacuation issues, unsafe smoking area placement, medication administration errors, incomplete resident support plans, and missing keypad code posting in the secured dementia unit. All deficiencies had plans of correction submitted and were implemented by October 18, 2023.

Citations (12)
Resident #1 contract was not signed by the resident.
Resident #1 and #2 do not have signed Resident Rights Forms.
Direct care staff person A did not receive required training in meeting resident needs, dementia care, and personal care service needs during 2022.
Room 209 does not have a light source that can be reached from the bedside.
The freezer inside the kitchen had a wrapped muffin without a label or date.
A fire drill was not conducted in May 2022.
The fire drill conducted on 7/22/2022 had 37 residents in the home, only 9 residents were evacuated.
Employee smoking area was located too close to dumpsters and combustible materials, posing a fire hazard.
Resident #3 and #4 medications were not available and not administered as prescribed on specified dates in January 2023.
Resident #2's support plan did not indicate dietary needs for soft, bite-sized food as required.
The code to the keypad in the secured dementia unit was not posted near the device on the inside of the unit.
Staff A did not complete 6 hours of dementia care and services training for training year 2022.
Report Facts
Residents Served: 36 Residents Served in Dementia Unit: 18 Current Hospice Residents: 15 Residents Age 60 or Older: 36 Residents with Mobility Need: 20 Total Daily Staff: 56 Waking Staff: 42

Employees mentioned
NameTitleContext
Staff ANamed in findings related to incomplete training and dementia care training.
AdministratorNamed in multiple findings related to training, plan of correction implementation, and oversight.
Assistant Director of NursingConducted medication audit to ensure prescriber orders are followed.
Director of NursingReviewed medication administration policies and involved in ongoing audits.
Maintenance DirectorResponsible for fire drills, smoking area relocation, and keypad code posting.

Inspection Report — Jul 31, 2023

Date: Jul 31, 2023

Visit Reason
The inspection was conducted as a licensing inspection due to an incident, with an unannounced partial inspection type.

Findings
No regulatory citations or deficiencies were identified as a result of this inspection.

Report Facts
Resident Support Staff: 36 Total Daily Staff: 92 Waking Staff: 69 Residents Served: 36 Secured Dementia Care Unit Residents Served: 16 Hospice Current Residents: 15 Residents Age 60 or Older: 36 Residents with Mobility Need: 20

Inspection Report — May 17, 2022

Renewal
Date: May 17, 2022

Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.

Findings
The inspection identified several deficiencies including missing emergency phone numbers by a resident's phone, lack of a thermometer in a freezer, incomplete fire drill records, incomplete medical evaluation documentation for a resident, inaccurate pre-admission screening form, and an unsecured gate in the secured dementia unit. Plans of correction were accepted and implemented with ongoing monitoring and staff training.

Citations (6)
Resident 1 has a landline phone in their room with no emergency numbers posted near it.
There was no thermometer in the freezer located in the kitchenette of Hall #2.
The fire drill record for the drill completed 12/14/2021 did not include the number of residents in the home or the number of residents evacuated from the home.
The Documentation of Medical Evaluation for Resident 2 was incomplete. The required field for body positioning was left blank.
The pre-admission screening form for Resident 3 states that their needs cannot be met by the home.
The gate exiting the secured dementia unit outside patio was not locked and allowed immediate egress to the side of the building leading to the parking lot.
Report Facts
Residents Served: 37 Residents in Secured Dementia Care Unit: 17 Hospice Residents: 4 Total Daily Staff: 57 Waking Staff: 43 Residents with Mobility Need: 20

Inspection Report — Jan 27, 2022

Complaint Investigation
Date: Jan 27, 2022

Visit Reason
The inspection was conducted as a complaint and incident investigation with unannounced partial review visits on 01/27/2022, 02/01/2022, and 02/03/2022.

Complaint Details
The visit was complaint-related and incident-driven. The complaint was substantiated as deficiencies were found regarding resident dignity and support plan adequacy.
Findings
The inspection found deficiencies related to the treatment of residents, specifically a resident being left partially undressed and exposed in a secured dementia unit, and inadequate documentation in the resident's support plan regarding supervision needs and care services. Plans of correction were submitted and fully implemented.

Citations (2)
Resident #1 was left without pants and socks in a common area, exposing private areas, violating dignity and respect requirements.
Resident #1's support plan did not indicate the correct level of supervision needed or outline how the home would meet the resident's increasing needs.
Report Facts
Residents Served: 37 Residents Served in Dementia Unit: 13 Hospice Residents: 6 Residents with Mobility Need: 19 Total Daily Staff: 56 Waking Staff: 42

Inspection Report — Dec 28, 2021

Routine
Date: Dec 28, 2021

Visit Reason
The inspection was conducted as a routine licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.

Findings
No regulatory citations were identified as a result of this inspection.

Inspection Report — Dec 15, 2021

Complaint Investigation
Date: Dec 15, 2021

Visit Reason
The inspection was conducted as a complaint investigation and incident review at Celebration Villa of Nittany Valley on 12/15/2021.

Complaint Details
The visit was complaint-related and incident-based, focusing on Resident #1's care and documentation. The plan of correction was fully implemented as of the report date.
Findings
The inspection found deficiencies related to Resident #1's medical evaluation documentation and support plan, including inaccurate dementia care designation and failure to update the support plan to address unsafe behaviors. Plans of correction were accepted and implemented.

Citations (2)
Resident #1's documentation of medical evaluation form indicated the need for secure dementia care, but the resident does not reside in the home's secure dementia unit.
Resident #1's support plan was not updated to reflect unsafe behaviors such as using disposable razors to cut hair, scissors to cut bedsheets, and an attempted elopement incident.
Report Facts
Residents Served: 34 Residents Served in Secured Dementia Care Unit: 13 Current Residents in Hospice: 4 Residents Age 60 or Older: 34 Residents with Mobility Need: 18

Inspection Report — Aug 5, 2021

Follow-Up
Date: Aug 5, 2021

Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 08/05/2021 to review the submitted plan of correction related to an incident involving resident abuse and other regulatory compliance issues.

Findings
The facility was found to have multiple deficiencies including resident-to-resident abuse, failure to implement positive interventions, incomplete preadmission screening forms, untimely medical evaluations, and failure to update support plans to reflect changes in resident conditions. The submitted plan of correction was determined to be fully implemented.

Citations (5)
Resident #1 pushed resident #2 causing a fractured hip; failure to prevent abuse.
Failure to implement positive interventions to modify or eliminate resident #1's abusive behavior.
Resident #1's preadmission screening form was not dated when completed.
Resident #1's medical evaluation was not completed within 60 days prior to admission.
Support plan for resident #1 was not updated to include seven incidents of physical harm towards other residents.
Report Facts
Residents Served: 29 Residents Served in Dementia Unit: 10 Hospice Residents: 3 Residents with Mobility Need: 14

Inspection Report — Jun 25, 2021

Renewal
Date: Jun 25, 2021

Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.

Findings
No regulatory citations were identified as a result of this inspection.

Inspection Report — Jun 24, 2021

Renewal
Date: Jun 24, 2021

Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.

Findings
No regulatory citations were identified as a result of this inspection.

Employees mentioned
NameTitleContext
Michele MoskalczykHuman Services Licensing SupervisorSigned the inspection report letter.

Notice — Jun 22, 2021

Date: Jun 22, 2021

Visit Reason
The document serves as a renewal license notification for Elmcroft of State College Personal Care Home, confirming receipt of the renewal application and advising of the requirement for an annual onsite inspection within the next twelve months.

Findings
No inspection findings are reported in this document; it is a licensing renewal notice confirming the issuance of a regular license and outlining the Department's inspection requirements.

Report Facts

Inspection Report — May 26, 2021

Renewal
Date: May 26, 2021

Visit Reason
The inspection was a full, unannounced renewal inspection conducted on 05/26/2021 and 05/27/2021 to assess compliance with licensing requirements.

Findings
The inspection identified multiple deficiencies including failure to timely report incidents and abuse, missing dates on carbon monoxide detector batteries, lack of annual fire safety training for some staff, uncovered trash receptacles, obstructed egress, inaccurate medication administration records, and incomplete resident assessments and support plans. Plans of correction were accepted for all deficiencies with monitoring and re-education scheduled.

Citations (10)
Failure to immediately report suspected abuse between residents as required by law.
Failure to report incidents such as hip fracture and medication errors to DHS within 24 hours.
Carbon monoxide detector batteries were not dated, preventing verification of annual checks.
Direct care staff did not receive required annual fire safety training in 2019.
Trash can in activities room was uncovered, violating sanitation requirements.
Door leading to back patio fire exit was blocked by an umbrella stand, obstructing egress.
Resident medical evaluations were not completed annually as required.
Medication Administration Records contained transcription errors of blood glucose readings.
Resident initial assessments and support plans were completed prior to admission dates.
Resident did not sign support plan despite participation in its development.
Report Facts
Residents Served: 32 Residents Served in Dementia Unit: 14 Total Daily Staff: 52 Waking Staff: 39 Completion Date: Jul 31, 2021

Inspection Report — May 14, 2021

Renewal
Date: May 14, 2021

Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.

Findings
No regulatory citations were identified as a result of this inspection.

Inspection Report — Apr 13, 2021

Plan of Correction
Date: Apr 13, 2021

Visit Reason
The inspection was conducted as a complaint and incident investigation to review compliance and the submitted plan of correction.

Complaint Details
The inspection was complaint-related and incident-based; substantiation status is not explicitly stated.
Findings
The report found two deficiencies: a repeat violation involving resident-to-resident physical abuse causing injury, and a medication administration violation where prescribed medication was unavailable and not administered as ordered. Both plans of correction were accepted and fully implemented.

Citations (2)
Resident 1 hit Resident 2 causing a swollen lip and a small cut; repeat violation of abuse prohibition.
Medication prescribed to Resident 1 was unavailable and not administered per prescriber's order.
Report Facts
Residents Served: 16 Secured Dementia Care Unit Residents Served: 15 Residents Age 60 or Older: 31 Residents with Mobility Need: 21 Current Hospice Residents: 3

Inspection Report — Mar 3, 2021

Plan of Correction
Date: Mar 3, 2021

Visit Reason
The inspection was conducted as a follow-up to verify that the previously submitted plan of correction was fully implemented following an incident-related partial inspection.

Findings
The plan of correction was determined to be fully implemented with continued compliance required. The original violations involved resident abuse and improper treatment, which were addressed through staff training and administrative actions.

Citations (2)
Resident 1 was physically abused by Resident 2 resulting in a dislocated shoulder.
Staff member B threatened to slap Resident 3's fingertips to deter door alarm activation.
Report Facts
Residents Served: 44 Secured Dementia Care Unit Residents Served: 14 Hospice Current Residents: 4 Total Daily Staff: 68 Waking Staff: 51

Inspection Report — Jan 28, 2021

Complaint Investigation
Date: Jan 28, 2021

Visit Reason
The inspection was conducted as a complaint investigation related to an allegation of resident abuse and incident reporting.

Complaint Details
The complaint involved an allegation of sexual assault by a staff person against Resident #1 on 12/27/2020. The facility failed to report the abuse timely, supervise or suspend the involved staff, notify the resident's POA, and submit required reports to the Department.
Findings
The facility failed to immediately report suspected abuse, did not implement appropriate supervision or suspension of involved staff, failed to notify the resident's designated person, and did not update the resident's support plan after an incident. Plans of correction were accepted and implemented with staff training completed.

Citations (6)
Failure to immediately report suspected abuse of a resident as required by the Older Adult Protective Services Act.
Failure to develop and implement a plan of supervision or suspend the staff person involved in the alleged abuse incident.
Failure to submit a plan of supervision or notice of suspension of the affected staff person to the Department.
Failure to immediately notify the resident and the resident’s designated person of a report of suspected abuse or neglect.
Failure to report the incident or condition to the Department’s personal care home regional office or complaint hotline within 24 hours.
Failure to revise the support plan after a resident fell out of bed and hit their head, ensuring resident safety.
Report Facts
Residents Served: 30 Secured Dementia Care Unit Residents Served: 14 Residents Age 60 or Older: 30 Residents with Mobility Need: 22 Staff Total Daily: 52 Staff Waking: 39

Inspection Report — Jan 21, 2021

Renewal
Date: Jan 21, 2021

Visit Reason
The inspection was conducted as part of the Pennsylvania Department of Human Services, Bureau of Human Service Licensing's licensing inspections on 01/21/2021, 01/22/2021, and 01/28/2021 for the facility Elmcroft of State College.

Findings
No regulatory citations were identified as a result of this inspection.

Inspection Report — Jan 14, 2021

Routine
Date: Jan 14, 2021

Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.

Findings
No regulatory citations or deficiencies were identified as a result of this inspection.

Employees mentioned
NameTitleContext
Michele MoskalczykHuman Services Licensing SupervisorSigned the inspection report letter.

Inspection Report — Nov 17, 2020

Follow-Up
Date: Nov 17, 2020

Visit Reason
The visit was a follow-up inspection triggered by a complaint to verify the implementation of a submitted plan of correction.

Complaint Details
The visit was complaint-related, triggered by a complaint regarding suspected abuse and treatment of resident #1. The complaint was substantiated as the investigation confirmed the incidents.
Findings
The facility was found to have fully implemented the plan of correction related to resident abuse, treatment of residents with dignity, and support plan revisions. Continued compliance must be maintained.

Citations (3)
15a - Resident Abuse Report: Staff failed to immediately report suspected abuse when staff person B took resident #1 by the arm and told them to leave the dining room after throwing dessert on the floor. The incident was reported through a complaint and staff person A did not report it to the administrator.
42c - Treatment of Residents: Resident #1 was not treated with dignity and respect when staff person B led the resident out of the dining room telling them to get out and go to their room. The incident was witnessed and reported via complaint.
234d - Support Plan Revision: Resident #1's support plan was not updated to reflect frequent falls and combative behavior, missing plans to address and decrease falls and behaviors.
Report Facts
Residents Served: 43 Dementia Unit Residents Served: 16 Resident Falls Dates: 9

Inspection Report — Oct 7, 2020

Routine
Date: Oct 7, 2020

Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.

Findings
No regulatory citations were identified as a result of this inspection.

Inspection Report — Sep 25, 2020

Renewal
Date: Sep 25, 2020

Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.

Findings
No regulatory citations were identified as a result of this inspection.

Inspection Report — Aug 5, 2020

Complaint Investigation
Date: Aug 5, 2020

Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 08/05/2020 and 08/06/2020 to review compliance with licensing regulations.

Complaint Details
The inspection was complaint-driven and included a follow-up to verify the plan of correction. The plan of correction was accepted and fully implemented.
Findings
The facility was found to have improperly disposed of discontinued medications and incomplete medication records lacking diagnosis or reason for medication. The submitted plan of correction was accepted and fully implemented.

Citations (2)
183f - Discontinued Medications: Medications belonging to a resident were disposed of in the garbage, which is not an approved method according to environmental and state regulations.
187a - Medication Record: A resident's medication record did not indicate a diagnosis or reason for the prescribed medication as required.
Report Facts
Residents Served: 44 Residents Served in Dementia Unit: 16 Hospice Current Residents: 5 Residents Age 60 or Older: 42 Residents with Mobility Need: 24

Notice — May 5, 2020

Date: May 5, 2020

Visit Reason
This document serves as a renewal notification and license issuance for Elmcroft of State College Personal Care Home. It informs the facility 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 the issuance of a regular license following the renewal application.

Report Facts

Inspection Report — Dec 6, 2019

Complaint Investigation
Date: Dec 6, 2019

Visit Reason
The inspection was a partial, unannounced visit conducted on December 6, 2019, triggered by a complaint and incident report.

Complaint Details
The complaint investigation substantiated multiple abuse incidents involving resident #1, including physical abuse and failure to report. The facility also failed to provide a meal to resident #2 as required.
Findings
The facility was found to have multiple violations related to resident abuse, failure to report incidents timely, mistreatment of residents, and missed meals. Plans of correction were implemented and approved.

Citations (5)
2600.15.a: The home did not immediately report suspected abuse that occurred on 11/19/19 involving rough handling of resident #1 by staff.
2600.16.c: The home failed to submit an incident report within 24 hours for the 11/19/19 abuse incident involving resident #1.
2600.42.b: Staff person "A" was physically rough with resident #1 on 11/20/19, including shoving, slapping, and punching.
2600.42.c: Resident #1 was not treated with dignity and respect on 11/19/19 when staff roughly uncovered the resident and removed clothing forcibly.
2600.162.b: Resident #2 was not provided an evening meal on 12/5/19 after declining earlier due to feeling unwell.
Report Facts
Residents Served: 49 Residents Served in Dementia Unit: 16 Current Hospice Residents: 6 Residents with Mobility Need: 22 Residents 60 Years or Older: 49 Residents with Physical Disability: 1

Employees mentioned
NameTitleContext
Casey MurphyAdministrator / Executive DirectorNamed in relation to abuse reporting and plan of correction implementation

Inspection Report — Aug 27, 2019

Complaint Investigation
Date: Aug 27, 2019

Visit Reason
The inspection was a complaint investigation conducted on August 27, 2019, to review citations related to Personal Care Homes regulations (55 Pa. Code Ch. 2600).

Complaint Details
The inspection was complaint-driven as indicated by the reason 'Complaint' on the inspection report. Specific complaints involved suspected resident abuse and medication errors. The alleged abuse was not substantiated but required immediate reporting and staff re-education.
Findings
Multiple violations were found including resident abuse, medication errors, failure to treat residents with dignity and respect, unsecured poisonous materials, incomplete medical evaluations, unlocked medications and syringes, and outdated support plans. The facility implemented plans of correction with ongoing monitoring and staff re-education.

Citations (9)
2600.15a: Resident #1's family member was observed yelling and attempting to open the resident's mouth. The alleged abuse was not reported to the local area agency on aging.
2600.16c: Resident #1's family member was observed yelling and attempting to open the resident's mouth. Resident #2 had a medication error with Prednisolone eye drops not taken as directed.
2600.42c: Resident #1's family member yelled and grabbed the resident's jaw during meal times. Resident #1 was not treated with dignity and respect.
2600.82c: Poisonous materials including men's speedstick and toothpaste were unlocked and accessible in the memory care unit.
2600.141a: Resident #2's DME dated 5/9/19 did not indicate anything for health status and cognitive functioning.
2600.183b: A bottle of systane eye drops was unlocked and unattended in Resident #2's bedroom. Medication must be kept in a locked container.
2600.187d: Resident #2 had multiple medication errors including incorrect administration of eye drops and insulin not given as ordered.
2600.231c: Resident #1's cognitive pre-admission screening dated 6/13/19 was not completed as required within 72 hours prior to admission.
2600.234d: Resident #1's support plan was not updated to reflect current care needs including two-person assist for transfers and supervision during feeding.
Report Facts
Residents Served: 52 Current Residents in Hospice: 7 Residents Served in Secured Dementia Unit: 17 Resident Mobility Need: 22 Residents Age 60 or Older: 52 Total Daily Staff: 74 Waking Staff: 56

Employees mentioned
NameTitleContext
Johanna RubleResident Service DirectorNamed in multiple findings related to re-education, plan of correction approval, and monitoring compliance.
Anne GrazianoHuman Services Licensing SupervisorSigned the cover letter and violation report.

Inspection Report — Jun 19, 2019

Annual Inspection
Date: Jun 19, 2019

Visit Reason
The visit was an annual inspection conducted by the Department’s Bureau of Human Services Licensing to assess compliance with 55 Pa. Code Chapter 2600 for Personal Care Homes, including renewal and incident review.

Findings
The inspection identified multiple violations related to resident confidentiality, refunds, sanitary conditions, soap dispenser labeling, emergency egress, secure medical care documentation, medication storage procedures, medication administration training, resident rights to refuse medication, timely assessments, and support plans. Plans of correction were partially implemented with ongoing monitoring.

Citations (11)
2600.17: Resident records were not kept confidential as privacy coding and assessment support plans were attached to the Licensing Inspection Summary.
2600.28a: Refund for resident #2 was not issued in accordance with the Elder Care Payment Restitution Act after the resident's death.
2600.85a: The refrigerator and freezer in the secured dementia care unit dining room were dirty at the time of inspection.
2600.102i: An unlabeled bar of soap was found on the sink in room 209, shared by two residents.
2600.121a: A large blanket was blocking the bottom of the emergency exit door in the garden room, obstructing immediate egress.
2600.142a: Resident #5’s Durable Medical Equipment did not have the medical professional’s name and license number documented.
2600.185a: Procedures for safe storage, access, security, distribution, and use of medications and medical equipment were not properly implemented; resident #1’s glucometer readings were inaccurately transcribed.
2600.190a: Annual medication administration practicum forms for two staff persons were incomplete and lacked trainer signatures and dates.
2600.191: Residents #3 and #4 were not educated on their right to question or refuse medication, risking medication errors.
2600.225a: Resident #3’s initial assessment was completed prior to the resident’s admission date, violating timely assessment requirements.
2600.227a: Resident #3’s support plan was completed prior to the resident’s admission date, violating support plan development timelines.
Report Facts
Residents Served: 49 Secured Dementia Care Unit Residents Served: 15 Current Hospice Residents: 5 Resident with Mobility Need: 21 Resident Age 60 or Older: 49 Total Daily Staff: 70 Waking Staff: 53

Employees mentioned
NameTitleContext
Johanna RubleOperations SpecialistNamed as Legal Entity Representative and signer of plans of correction.

Inspection Report — Mar 28, 2019

Renewal
Date: Mar 28, 2019

Visit Reason
This document is a renewal of the facility license for Elmcroft of State College, a Personal Care Home, confirming receipt of the renewal application and advising that an onsite inspection will be conducted within the next twelve months.

Findings
No inspection findings are reported in this document. It serves as a license renewal notification and states that enforcement action may be taken if noncompliance is found during the upcoming inspection.

Report Facts

Inspection Report — Mar 7, 2019

Complaint Investigation
Date: Mar 7, 2019

Visit Reason
The inspection was conducted as a complaint investigation at Elmcroft of State College to assess compliance with 55 Pa. Code Chapter 2600 related to Personal Care Homes.

Complaint Details
The inspection was complaint-driven. Specific complaints involved inadequate assistance with showers and medication administration errors including refusals and failure to notify prescribers.
Findings
The inspection identified violations related to resident care including insufficient assistance with daily living activities and medication administration errors. Plans of correction were submitted addressing shower frequency and medication refusals.

Citations (3)
55 Pa.Code §2600.23(b) - The facility failed to provide each resident with assistance for instrumental activities of daily living as indicated in the resident's assessment and support plan. Resident #1 only received one shower during the week of 02/10-02/16/19 instead of the prescribed two showers per week.
55 Pa.Code §2600.187(c) - The facility failed to document refusals of prescribed medication in the resident's record and notify the prescriber within 24 hours as required. Resident #2 refused multiple medications and the prescriber was not notified.
55 Pa.Code §2600.187(d) - The facility failed to follow the directions of the prescriber for Resident #2, who had an order for oxymorphone PRN that was inconsistently administered and later discontinued without proper documentation.
Report Facts
Number of Residents Served: 51 Number of Residents 60 Years or Older: 51 Number of Residents with Mobility Need: 23 Number of Current Hospice Residents: 6 Number of Hospice Residents in Past Year: 12

Employees mentioned
NameTitleContext
Brandi ButlerAdministrator, EDSigned plans of correction and named as administrator in report

Inspection Report — Dec 20, 2018

Complaint Investigation
Date: Dec 20, 2018

Visit Reason
The inspection was conducted as a complaint investigation at Elmcroft of State College on December 20, 2018.

Complaint Details
The inspection was complaint-driven as stated on page 2. No substantiation status was provided.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found, including failure to post the current Certificate of Compliance, missing weekly menus, medication administration errors, incomplete resident support plans, and missing conspicuous posting of keypad codes for secured dementia care unit exits.

Citations (5)
55 Pa.Code §2600.3(c) - The current Certificate of Compliance license number 233740 issued 09/28/18 was not posted as required.
55 Pa.Code §2600.162(c) - Weekly menus for the dining and activity rooms from 12/09/18 to 12/29/18 were not posted as required.
55 Pa.Code §2600.182(c) - Staff member administered medications to two residents simultaneously and did not document medication administration correctly.
55 Pa.Code §2600.227(d) - Resident #3's support plan did not reflect implanted pacemaker and related diagnoses as documented in medical evaluations.
55 Pa.Code §2600.233(c) - The code for keypad door exiting the secured dementia care unit was not posted conspicuously as required.
Report Facts
Number of Residents Served: 51 Number of Current Hospice Residents: 5 Number of Hospice Residents in Past Year: 12 Number of Residents Age 60 or Older: 51 Number of Residents with Mobility Need: 24 Number of Residents with Physical Disability: 1

Inspection Report — Sep 28, 2018

Renewal
Date: Sep 28, 2018

Visit Reason
This document serves as a revised license issued due to the realignment of the Bureau of Human Services Licensing's regional offices and the change in the Certificate of Compliance number for Elmcroft of State College.

Findings
The revised license confirms the Certificate of Compliance number has changed from 333740 to 233740, with the expiration date remaining unchanged. The facility is licensed to provide personal care home services with a maximum capacity of 60 persons.

Report Facts

Employees mentioned
NameTitleContext
Jacqueline L. RoweDirectorSigned the letter enclosing the revised license

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