Inspection Reports for
Celebration Villa of Reedsville
55 Carriage House Ln, Reedsville, PA 17084, Reedsville, PA, 17084
Back to Facility Profile15 Reports
Inspection Report — Nov 18, 2025
Renewal
Date: Nov 18, 2025
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license to ensure compliance with regulatory requirements.
Findings
The inspection identified multiple deficiencies including lack of certified CPR-trained staff during overnight hours, improper freezer temperatures, presence of outdated food, non-compliant smoking area furnishings, incomplete resident medication self-administration assessments, and discontinued medications remaining in the medication cart. All deficiencies had accepted plans of correction with implementation dates in January 2026.
Citations (6)
Regulation 2600.63.a: No staff certified in obstructed airway techniques and CPR were present from 10:00 PM to 6:00 AM while 42 residents were in the home.
Regulation 2600.103.f: Freezer temperatures were recorded at 6°F and 4°F, exceeding the required 0°F maximum for frozen food storage.
Regulation 2600.103.i: A dented 6 lb. can of peaches was found in the dry food storage area.
Regulation 2600.144.c.1: The designated smoking area had a chair cushion without a label indicating it was fire retardant.
Regulation 2600.181.c: Residents self-administering medications were not assessed by a qualified medical professional regarding their ability and need for reminders.
Regulation 2600.183.d: Discontinued medication was found in the home's medication cart for a resident.
Report Facts
Residents served: 42
Current hospice residents: 10
Residents aged 60 or older: 42
Residents with mobility need: 19
Residents with physical disability: 1
Inspection Report — May 13, 2025
Follow-Up
Date: May 13, 2025
Visit Reason
The inspection was conducted as a partial, unannounced visit due to a complaint and incident, with follow-up on the submitted plan of correction.
Complaint Details
The inspection was triggered by a complaint and incident as stated under Inspection Information Reason.
Findings
The submitted plan of correction was determined to be fully implemented as of the review dates 05/13/2025, 05/15/2025, and 05/16/2025. Deficiencies related to staff training on medication self-administration, resident needs, fire safety, and the Older Adult Protective Services Act were identified and addressed with corrective actions and ongoing monitoring.
Citations (2)
Staff member A did not receive training in medication self-administration and instruction on meeting the needs of residents as described in the preadmission screening form, assessment tool, medical evaluation, and support plan during the 2024 training year.
Staff member A did not receive training in fire safety completed by a fire safety expert or trained staff, and training on the Older Adult Protective Services Act during the 2024 training year.
Report Facts
Residents Served: 41
Current Residents: 7
Direct Care Staff Annual Training Completion Date: Jun 30, 2025
Follow-Up Date: May 30, 2025
Notice — Feb 23, 2025
Date: Feb 23, 2025
Visit Reason
The document is a response to a facility's request for a waiver of Pennsylvania medication administration training regulations to allow unlicensed direct care staff to administer subcutaneous injections of GLP-1 agonist medications.
Findings
The waiver outlines specific 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 professionals, and annual training hours related to GLP-1 medications and diabetes management. The facility must have policies and clinical contacts in place to support safe administration and monitoring.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Inspection Report — Nov 19, 2024
Renewal
Date: Nov 19, 2024
Visit Reason
The inspection was conducted as a full, unannounced visit for renewal and complaint reasons on 11/19/2024 and 11/20/2024.
Complaint Details
The inspection included complaint investigation as part of the renewal process, but no specific substantiation status was stated.
Findings
The inspection identified multiple deficiencies including breaches in record confidentiality, lack of CPR/First Aid trained staff during overnight hours, incomplete fire drill records, inaccurate fire drill participation documentation, failure to follow prescriber's orders, incomplete resident assessments, and unsigned support plans. All deficiencies had plans of correction accepted and were implemented by 01/15/2025.
Citations (7)
Resident records were stored in plain sight and accessible with the nurse's office door propped open and no staff present.
No staff persons certified in CPR and First Aid were present in the home from 10 PM to 6 AM on inspection dates.
Fire drill records did not list the exit routes used for drills conducted on specified dates.
Fire drill records showed 3 staff participating during overnight drills when only 2 staff were working.
Prescriber's orders were not followed, including medication errors and delayed availability of hospice medications.
Resident assessment and support plan was not updated to reflect hospice care services.
Resident participated in support plan development but did not sign the support plan.
Report Facts
Residents Served: 37
Total Daily Staff: 49
Waking Staff: 37
Residents with Mobility Need: 12
Current Hospice Residents: 1
Inspection Report — Jan 31, 2024
Renewal
Date: Jan 31, 2024
Visit Reason
The inspection was conducted as a renewal and complaint investigation for the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 36
Current Hospice Residents: 5
Residents Age 60 or Older: 36
Residents with Mobility Need: 13
Residents with Physical Disability: 1
Inspection Report — Dec 14, 2022
Renewal
Date: Dec 14, 2022
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 12/14/2022 to review compliance with licensing regulations and contract requirements.
Findings
The inspection identified multiple deficiencies including missing influenza information posters, contract issues regarding fees, annual assessments, refunds, termination conditions, complaint procedures, signed statements, hot water temperature violations, combustible storage near heat sources, missing fire drills and fire drill documentation, medication record omissions, insulin administration without proper certification, and delayed resident assessments. Plans of correction were accepted and implemented with proposed completion dates by 01/30/2023.
Citations (17)
No influenza information posted as required by the Influenza Awareness Act.
Resident-home contracts incorrectly charging additional fees for housekeeping included in personal care.
Resident-home contracts do not explain annual assessment, medical evaluation, and support plan requirements.
Resident-home contracts do not specify refund conditions upon resident's death.
Resident-home contracts do not specify conditions for termination including types of assistance provided.
Resident-home contracts lack complaint procedures and resident rights information.
Resident-home contracts do not include information on whether the home will seek or accept resident rent rebate.
Records for some residents lack signed statements acknowledging receipt of resident rights and complaint procedures.
Hot water temperature in bathrooms of Bedrooms 139 and 145 exceeded 120°F.
Two 5-gallon cans of paint stored near gas-powered hot water heater in mechanical room.
Unannounced fire drills were not held during December 2021, January 2022, June 2022, August 2022, or October 2022.
Fire drill records for drills conducted on 02/28/2022, 03/22/22, 04/29/22, and 05/31/2022 did not include exit routes used.
No fire drills conducted during sleeping hours for the past 12 months.
Medication administration records for Resident 1 and Resident 3 do not indicate diagnosis or purpose for medications.
Staff person administered insulin without completing required diabetes patient education program within past 12 months.
Resident 4's initial assessment was not completed within 15 days of admission.
Resident 3's most recent annual assessment was not completed timely.
Report Facts
Residents Served: 34
Hot Water Temperature: 123.5
Hot Water Temperature: 126.6
Fire Drill Months Missed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person A | Named in insulin administration violation for not completing required diabetes education | |
| Director of Nursing | Named in multiple findings including posting influenza information, updating medication records, and training staff | |
| Assistant Director of Nursing | Named in medication record updates and staff training | |
| Maintenance Director | Named in findings related to hot water temperature correction, combustible storage removal, and fire drill completion | |
| Executive Director | Named in multiple findings for training, oversight, and ensuring compliance |
Inspection Report — Nov 12, 2021
Complaint Investigation
Date: Nov 12, 2021
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on 11/12/2021, 11/29/2021, and 12/15/2021 to review compliance and follow up on submitted plans of correction.
Complaint Details
The visit was complaint-related with substantiation implied by identification of multiple medication errors and failure to administer prescribed medications due to unavailability.
Findings
Multiple medication errors involving residents 2, 3, and 4 were identified during the inspection. Additional violations included uncovered trash dumpsters and improper medication storage. Plans of correction were submitted and fully implemented by the facility.
Citations (5)
Multiple medication errors involving Residents 2, 3, and 4 were identified during the inspection; none were reported to the Department.
Trash in the partially full dumpster was uncovered because two of the lids were open.
One resident's medication tablets were stored in a blister card that had been popped open and then reclosed with tape.
Resident 4 was prescribed medication but it was not administered as prescribed on multiple dates because it was not available in the home.
Resident 2 and Resident 3 were prescribed medications that were not administered on multiple dates because they were not available in the home.
Report Facts
Residents Served: 34
Staffing Hours - Total Daily Staff: 43
Staffing Hours - Waking Staff: 32
Residents with Mobility Need: 9
Residents Age 60 or Older: 34
Residents with Physical Disability: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gloria Emick | Reviewer | Reviewer of follow-up document submissions |
Notice — Jul 14, 2021
Date: Jul 14, 2021
Visit Reason
The document serves as a certificate of compliance and notification of license renewal for Elmcroft of Reedsville, a Personal Care Home, and advises that an annual inspection will be conducted within the next twelve months.
Findings
No inspection findings are reported in this document; it confirms issuance of a regular license following the renewal application and outlines the requirement for an annual inspection.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
Inspection Report — May 20, 2021
Renewal
Date: May 20, 2021
Visit Reason
The inspection was an unannounced renewal inspection conducted to review compliance with licensing regulations and verify the implementation of the submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented. Several deficiencies were identified related to criminal background checks, staff qualifications, first aid/CPR training, orientation, trash receptacles, medication refusal documentation, follow prescriber's orders, insulin injections, and resident rights to refuse medication. All deficiencies included plans of correction with specified actions and ongoing monitoring.
Citations (9)
Staff Person A had no record of a criminal background check and Staff Person B did not have a criminal history background check until a later date.
Direct Care Staff Person A does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
No staff persons certified in First Aid/CPR were present during multiple specified dates and times.
Staff Person A did not receive orientation on evacuation procedures, fire drills, emergency evacuation, smoking safety, fire extinguishers, smoke detectors, fire alarms, and telephone use until after the first day of work.
Trash receptacles in shared bathrooms of Rooms #149 and #151 were not covered on 5/20/2021.
Resident #3 refused prescribed medication but the prescriber was not notified of the refusals.
Resident #2's medication prescribed for daily administration was not administered as it was not available in the home.
Staff Person B had not successfully completed a Department-approved diabetes education program but administered insulin to Resident #2.
Resident #2 was not educated on the right to refuse medication despite the resident believing there may be a medication error.
Report Facts
Residents Served: 39
Staffing Hours: 45
Waking Staff: 34
Current Residents: 0
Residents Age 60 or Older: 38
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 6
Inspection Report — Jan 26, 2021
Follow-Up
Date: Jan 26, 2021
Visit Reason
The visit was a follow-up inspection to verify the implementation of a previously submitted plan of correction related to medication administration deficiencies.
Findings
The submitted plan of correction was found to be fully implemented, with all medication administration record deficiencies addressed and staff re-trained on relevant regulations.
Citations (2)
The medication administration record for Resident 1 did not include the duration for Cefdinir 300 mg capsule or a diagnosis or purpose for the medication.
Resident 1 was prescribed Cefdinir 300 mg capsule, 1 capsule twice daily. This medication was not given on 1/13/2021 at 7am but was given at 7pm with another, newly prescribed medication.
Report Facts
Residents Served: 31
Total Daily Staff: 37
Waking Staff: 28
Inspection Report — Jun 20, 2019
Renewal
Date: Jun 20, 2019
Visit Reason
The inspection was a renewal visit conducted by the Department’s Bureau of Human Services Licensing to assess compliance with 55 Pa.Code Chapter 2600 for Personal Care Homes.
Findings
Multiple violations of state regulations were found, including failure to post current license, issues with resident refunds, training deficiencies, hot water temperature exceeding limits, and fire drill record inconsistencies. Plans of correction were implemented and partially or fully completed by the time of report approval.
Citations (11)
Regulation 3c: The home did not post a copy of Chapter 2600 regulations in a conspicuous and public place.
Regulation 28e: The home failed to issue a refund in accordance with the Elder Care Restitution Act for a deceased resident under 60 years of age.
Regulation 28f: The home did not issue a refund for a discharged resident’s belongings within 30 days of discharge.
Regulation 65d.2: A direct care staff person provided unsupervised ADL services before completing required training and competency testing.
Regulation 89b: Hot water temperature in the women's shower room sink exceeded 120°F, measuring 122.1°F.
Regulation 132c: The home had inconsistent fire drill records with varying evacuation times for drills conducted on 7/31/18.
Regulation 132f: Alternate exit routes were not used during fire drills as required, using the same exits repeatedly.
Regulation 132g: Fire drills were not held on different days and times as required, and not routinely held when additional staff were present.
Regulation 141a: A resident’s medical evaluation did not include temperature or ability to self-administer medications.
Regulation 141b1: A resident’s annual medical evaluation was not completed timely, with the previous evaluation over two years old.
Regulation 191: Residents were not educated on their right to refuse medication, and documentation of education was lacking.
Report Facts
Residents Served: 48
Hot Water Temperature: 122.1
Fire Drill Evacuation Times: Evacuation times recorded were 2 minutes 43 seconds, 10 minutes 42 seconds, and 12 minutes
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Faithe Soles | Executive Director | Named as the Executive Director responsible for plans of correction and signatures on multiple violation reports |
Notice — Apr 15, 2019
Date: Apr 15, 2019
Visit Reason
The document serves as a renewal notification for the Personal Care Home license and includes the certificate of occupancy specifying the maximum capacity permitted.
Findings
No inspection findings are reported in this document. It confirms receipt of the renewal application and issuance of the license.
Report Facts
Inspection Report — Feb 11, 2019
Complaint Investigation
Date: Feb 11, 2019
Visit Reason
The inspection was conducted as a complaint investigation of the Elmcroft of Reedsville personal care home on February 11, 2019.
Complaint Details
The inspection was triggered by a complaint. Specific substantiation status is not stated.
Findings
The inspection found violations related to facility maintenance, specifically ceiling tiles that were discolored and damaged due to moisture and sagging. A plan of correction was implemented to replace the affected ceiling tiles and address the root cause.
Citations (1)
55 Pa.Code §2600.88(a) - Floors, walls, ceilings, windows, doors and other surfaces must be clean, in good repair and free of hazards. Three ceiling tiles outside the dining room were discolored from moisture and sagging, with additional damaged tiles at hallway junctions.
Report Facts
Number of Residents Served: 48
Number of Current Hospice Residents: 2
Number of Hospice Residents in past year: 4
Residents Age 60 or Older: 48
Residents with Mobility Need: 7
Inspection Report — Jun 15, 2018
Original Licensing
Date: Jun 15, 2018
Visit Reason
The inspection was conducted as an initial 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.
Notice — June 10, 2020
Date: June 10, 2020
Visit Reason
This document serves as a renewal notification and certificate of compliance for the Personal Care Home 'Elmcroft of Reedsville'. It informs the facility that the Department will conduct an onsite annual inspection 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 following the renewal application.
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