Inspection Reports for
Celebration Villa of Mid Valley
67 Sturges Rd, Peckville, PA 18452, Peckville, PA, 18452
Back to Facility Profile47 Reports
Inspection Report — Mar 25, 2026
Renewal
Date: Mar 25, 2026
Visit Reason
The document is a renewal application and license issuance for Celebration Villa of Mid Valley Personal Care Home. The Department will conduct an onsite inspection within the next twelve months as required by regulation.
Findings
A regular license is being issued in response to the renewal application. The Department will take enforcement action if noncompliance is found during the upcoming inspection.
Inspection Report — Jan 29, 2026
Follow-Up
Date: Jan 29, 2026
Visit Reason
The inspection was a follow-up review to verify the implementation of a previously submitted plan of correction related to a complaint and incident.
Complaint Details
The inspection was complaint-related and incident-driven, as indicated by the reason 'Complaint, Incident'.
Findings
The submitted plan of correction was determined to be fully implemented as of the review dates. Continued compliance must be maintained.
Citations (1)
2600.225.c requires additional resident assessments if the resident's condition significantly changes prior to the annual assessment. Resident assessment did not include behaviors such as approaching and touching other residents and the need for 15-minute checks.
Report Facts
Residents Served: 34
Current Hospice Residents: 3
Residents Who Have Mobility Need: 34
Residents Who Are 60 Years of Age or Older: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Director of Clinical | Provided training on regulation 2600.225c to Executive Director and Director of Nursing | |
| Executive Director | Received training on regulation 2600.225c and involved in audit and plan of correction | |
| Director of Nursing | Reviewed and updated resident support plan; received training on regulation 2600.225c; involved in audits |
Inspection Report — Dec 23, 2025
Follow-Up
Date: Dec 23, 2025
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident at the facility.
Findings
The inspection found a violation of regulation 2600.42b regarding resident abuse where one resident pushed another causing injury requiring hospital treatment. The facility implemented a plan of correction including staff training and ongoing quality assurance monitoring.
Citations (1)
Regulation 2600.42b: A resident was physically abused when one resident pushed another causing the latter to fall and sustain head injuries requiring two staples. The facility transported both residents for medical evaluation and placed them under close observation.
Report Facts
Residents served: 35
Hospice Current Residents: 2
Inspection Report — Jun 26, 2025
Date: Jun 26, 2025
Visit Reason
The inspection was a partial, unannounced licensing inspection conducted due to an incident.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Resident Support Staff: 1
Total Daily Staff: 89
Waking Staff: 67
Residents Served: 59
Residents Served in Secured Dementia Care Unit: 29
Current Hospice Residents: 2
Residents with Mobility Need: 29
Inspection Report — Jun 5, 2025
Date: Jun 5, 2025
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 during this inspection.
Report Facts
Residents Served: 31
Current Hospice Residents: 1
Resident Support Staff: 0
Total Daily Staff: 62
Waking Staff: 47
Residents Age 60 or Older: 31
Residents with Mobility Need: 31
Inspection Report — May 29, 2025
Follow-Up
Date: May 29, 2025
Visit Reason
The inspection visit on 05/29/2025 was conducted as a partial, unannounced follow-up to verify the implementation of a previously submitted plan of correction related to an incident.
Findings
The submitted plan of correction was determined to be fully implemented as of the inspection date. Deficiencies related to annual medical evaluations and support plan revisions were addressed with corrective actions, training, and ongoing monitoring initiated.
Citations (2)
Resident's annual medical evaluation was overdue and not completed by the required date.
Annual support plan for a resident was not completed by the required date, constituting a repeat violation.
Report Facts
Residents Served: 32
Current Hospice Residents: 1
Total Daily Staff: 64
Waking Staff: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Named in corrective actions and training related to deficiencies | |
| Director of Nursing | Named in corrective actions and training related to deficiencies | |
| Regional Director of Operations | Provided training on regulations and compliance tools | |
| Regional Director of Clinical Services | Trained staff on version tracking tool and tickler system | |
| Resident Care Coordinator | Involved in training and ongoing audits for compliance |
Inspection Report — Mar 11, 2025
Follow-Up
Date: Mar 11, 2025
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by a complaint and incident to verify the implementation of a previously submitted plan of correction.
Complaint Details
The inspection was conducted due to a complaint and incident. The submitted plan of correction was determined to be fully implemented.
Findings
The facility was found to have fully implemented the submitted plan of correction. Two deficiencies were noted: failure to conspicuously post the code for the key-locking device at the secure dementia unit exit, and failure to update a resident's support plan to reflect combative behaviors and multiple falls resulting in injury. Both deficiencies were corrected and staff were educated accordingly.
Citations (2)
The home did not have the code posted conspicuously at or near the keypad used to operate the door that exits the secure dementia unit into the lobby.
The home did not update the support plan for a resident to address combative behaviors and multiple falls resulting in head lacerations requiring sutures.
Report Facts
Residents Served: 30
Current Residents in Hospice: 1
Residents Age 60 or Older: 30
Residents with Mobility Need: 30
Staffing Hours - Total Daily Staff: 60
Staffing Hours - Waking Staff: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Educated staff on regulation 2600.233c and 2600.234A; involved in audits and oversight of plan of correction | |
| Director of Nursing | Educated on regulations and involved in updating support plans and audits | |
| Resident Care Coordinator | Updated resident support plan and involved in audits and staff education | |
| Regional Director of Clinical Services | Educated Executive Director, Director of Nursing, and Resident Care Coordinator on relevant regulations | |
| Maintenance Director | Involved in auditing the posting of the keypad code |
Inspection Report — Feb 5, 2025
Complaint Investigation
Date: Feb 5, 2025
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection of the facility on 02/05/2025.
Complaint Details
The inspection was complaint-driven and unannounced, but no deficiencies or citations were found, indicating no substantiated issues.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 32
Resident Support Staff: 0
Total Daily Staff: 64
Waking Staff: 48
Inspection Report — Jan 22, 2025
Follow-Up
Date: Jan 22, 2025
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The submitted plan of correction was found to be fully implemented, with updates made to the resident support plan to reflect physical therapy services and safety checks. Continued compliance must be maintained.
Citations (1)
The support plan was not updated to document physical therapy services and 15-minute safety checks after a resident's recent fall.
Report Facts
Residents Served: 31
Staffing Hours - Total Daily Staff: 62
Staffing Hours - Waking Staff: 47
Hospice Current Residents: 1
Residents Age 60 or Older: 31
Residents with Mobility Need: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Director of Clinical Services | Updated support plan to reflect physical therapy services and safety checks | |
| New Director of Nursing | Director of Nursing | Educated on updating support plans and responsible for maintaining support plans |
| Resident Care Coordinator | Educated on updating support plans and involved in reviewing support plans | |
| Executive Director | Responsible for reviewing support plans and monitoring compliance |
Notice — Nov 12, 2024
Date: Nov 12, 2024
Visit Reason
The document is 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 a Department-approved medication administration course, in-person training by licensed health care professionals, and annual training hours. The facility must have policies and clinical contacts in place to monitor and support medication administration.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Inspection Report — Oct 29, 2024
Renewal
Date: Oct 29, 2024
Visit Reason
The inspection was conducted as a full, unannounced review for renewal, complaint, and incident reasons.
Findings
Multiple deficiencies were identified including abuse incidents, unsecured poisonous materials, missing emergency phone numbers, broken window screens, missing refrigerator/freezer thermometers, fire extinguisher inspection tag missing, incomplete fire drill records, exceeded evacuation time during fire drill, missing exit signage, discontinued medications still present, and missing directions for keypad operation on locked doors. Plans of correction were accepted and implemented by 01/07/2025.
Citations (11)
Resident abuse incident involving physical altercation resulting in injury requiring surgery.
Unlocked housekeeping cart with poisonous materials accessible to residents.
Emergency telephone numbers not posted near landline telephone.
Broken and cracked window screen in dining room.
Refrigerator and freezer lacked thermometers.
Fire extinguisher missing inspection tag.
Fire drill log did not include exact evacuation time in minutes and seconds.
Fire drill evacuation time exceeded the maximum allowed 6 minutes.
Exterior door to secure courtyard missing exit signage.
Discontinued medication still present in medication cart.
Directions for keypad operation on locked doors not posted.
Report Facts
Residents served: 29
Total daily staff: 58
Waking staff: 44
Current hospice residents: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in medication removal and monitoring of aggressive resident behaviors |
| Resident Care Coordinator | Resident Care Coordinator | Involved in medication cart audit and monitoring fire extinguisher tag removal |
| Executive Director | Executive Director | Responsible for multiple corrective actions including removal of poisonous materials, replacement of emergency phone lists, fire drill log updates, and signage replacement |
| Maintenance Director | Maintenance Director | Responsible for fixing window screens and fire drill log compliance |
Inspection Report — Sep 24, 2024
Complaint Investigation
Date: Sep 24, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation at the facility.
Complaint Details
The inspection was complaint-related and incident-based; no deficiencies or citations were found.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Residents Served: 36
Current Residents in Hospice: 1
Resident Support Staff: 0
Total Daily Staff: 72
Waking Staff: 54
Residents Age 60 or Older: 36
Residents with Mobility Need: 36
Inspection Report — Aug 15, 2024
Date: Aug 15, 2024
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
Total Daily Staff: 76
Waking Staff: 57
Residents Served: 38
Secured Dementia Care Unit Residents Served: 38
Current Hospice Residents: 2
Residents Age 60 or Older: 37
Residents with Mobility Need: 38
Inspection Report — Jul 25, 2024
Follow-Up
Date: Jul 25, 2024
Visit Reason
The inspection visit on 07/25/2024 was a partial, unannounced follow-up to verify the implementation of a previously submitted plan of correction related to an incident.
Findings
The submitted plan of correction was determined to be fully implemented. The report details a violation where a staff member was found to have treated a resident without dignity and respect, resulting in the staff member's termination and staff training on resident rights.
Citations (1)
Staff member placed hands on resident #1 and forced resident into a dining room chair during dinner, violating dignity and respect requirements.
Report Facts
Residents Served: 38
Current Residents in Hospice: 4
Residents Age 60 or Older: 38
Residents with Mobility Need: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Reported incident and terminated staff member A after investigation | |
| Staff member A | Involved in the violation of resident dignity and respect |
Inspection Report — Jul 3, 2024
Complaint Investigation
Date: Jul 3, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation at the facility.
Complaint Details
The inspection was complaint-related with no deficiencies found and no follow-up required.
Findings
No regulatory citations or deficiencies were identified during this unannounced partial inspection.
Report Facts
Residents Served: 41
Total Daily Staff: 82
Waking Staff: 62
Current Hospice Residents: 5
Residents Age 60 or Older: 41
Residents with Mobility Need: 41
Inspection Report — May 7, 2024
Date: May 7, 2024
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident at the facility on 05/07/2024.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
Residents Served: 42
Current Hospice Residents: 4
Resident Support Staff Hours: 84
Waking Staff Hours: 63
Inspection Report — Mar 6, 2024
Complaint Investigation
Date: Mar 6, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation during an unannounced partial inspection on 03/06/2024.
Complaint Details
The inspection was complaint-related, but no deficiencies were found and follow-up was not required.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 44
Current Hospice Residents: 4
Total Daily Staff: 88
Waking Staff: 66
Residents Age 60 or Older: 44
Residents with Mobility Need: 44
Inspection Report — Jan 25, 2024
Date: Jan 25, 2024
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 as a result of this inspection.
Report Facts
Residents Served: 44
Current Hospice Residents: 4
Total Daily Staff: 88
Waking Staff: 66
Notice — Jan 17, 2024
Date: Jan 17, 2024
Visit Reason
Response to a request submitted by the facility to use the Safely You Falls Management Program to support fall detection and fall management for individuals with cognitive impairment.
Findings
The Department reviewed the submitted information and found that the informed consent process includes voluntary participation, the right to discontinue use of cameras, and that residents and responsible parties are informed of their rights. Maintaining the outlined practices satisfies regulatory requirements around residents' right to privacy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Director, Bureau of Human Services Licensing | Signed the response letter regarding the Safely You Falls Management Program. |
Inspection Report — Jan 16, 2024
Complaint Investigation
Date: Jan 16, 2024
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection of the facility on 01/16/2024.
Complaint Details
The inspection was complaint-related, but no deficiencies were found and no follow-up was required.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 42
Current Residents in Hospice: 4
Total Daily Staff: 84
Waking Staff: 63
Inspection Report — Jan 12, 2024
Date: Jan 12, 2024
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Resident Support Staff: 44
Total Daily Staff: 132
Waking Staff: 99
Hospice Current Residents: 5
Residents Served: 44
Inspection Report — Dec 1, 2023
Complaint Investigation
Date: Dec 1, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation at Celebration Villa of Mid Valley on 12/01/2023.
Complaint Details
The visit was triggered by a complaint and incident, with findings substantiated by the State Representative during the visit on 12/01/2023.
Findings
Two deficiencies were identified related to sanitary conditions and following prescriber's orders, both of which were addressed with corrective actions including staff training and auditing systems. The submitted plan of correction was fully implemented as of 01/19/2024.
Citations (2)
The glucometer of Resident #1 was used to measure the blood glucose of Resident #2, violating sanitary conditions.
Resident #3 received an incorrect dose of medication, violating the requirement to follow prescriber's orders.
Report Facts
Residents Served: 44
Current Hospice Residents: 2
Resident Support Staff: 44
Total Daily Staff: 132
Waking Staff: 99
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in corrective actions and training related to deficiencies |
| Assistant Director of Nursing | Assistant Director of Nursing | Involved in training and auditing related to deficiencies |
Inspection Report — Aug 29, 2023
Renewal
Date: Aug 29, 2023
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing regulations and verify the submitted plan of correction.
Findings
The inspection identified multiple deficiencies including failure to post the most recent annual license inspection summary, unsanitary conditions such as urine odor and overflowing garbage, hazards from damaged weatherstripping, missing emergency telephone numbers, combustible materials improperly stored, smoking area violations, and medication storage and documentation issues. All deficiencies had plans of correction accepted and were implemented by 10/11/2023.
Citations (9)
The most recent annual License Inspection Summary from 6/7/2022 was not posted in the home at the time of inspection.
Strong odor of urine near the main entry door to the secured dementia unit and overflowing garbage can on the outdoor patio.
Weatherstripping of the courtyard door in Hallway A was hanging from the door frame creating a hazard.
No emergency telephone numbers posted near the landline phone outside the medication room.
10-15 cigarette butts observed in the mulch in front of the home near a heat source.
Resident 1 had discontinued prescription medications still available on the medication cart.
Resident 2’s glucometer reading was documented incorrectly and Resident 3 had PRN orders not available if needed.
Resident 1 had a PRN order that was not added to the Medication Administration Record (MAR).
Door exiting the secured outside patio to the parking lot was unable to be opened from the keypad preventing immediate egress.
Report Facts
Residents Served: 41
Current Residents in Hospice: 4
Cigarette Butts: 10
Cigarette Butts: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in medication storage and medication record deficiencies and corrective actions |
| Executive Director | Executive Director | Named in deficiencies related to posting license summary, sanitary conditions, surfaces, emergency telephone numbers, combustible storage, and key-locking devices |
| Maintenance Director | Maintenance Director | Named in deficiencies related to sanitary conditions, combustible storage, and key-locking devices |
Inspection Report — Jul 26, 2023
Follow-Up
Date: Jul 26, 2023
Visit Reason
The inspection was a partial, unannounced visit conducted due to a complaint and incident, with follow-up reviews related to a plan of correction submission.
Complaint Details
The visit was complaint-related due to an incident of resident abuse involving physical assault between residents. The plan of correction was accepted and fully implemented.
Findings
The report found that a resident punched another resident resulting in a fall and injury, with medical evaluations and increased monitoring implemented. The submitted plan of correction was determined to be fully implemented as of the follow-up date.
Citations (1)
Resident #1 punched resident #2 in the face two times resulting in resident #2 falling to the floor. The two residents were medically evaluated after the altercation.
Report Facts
Residents Served: 42
Current Residents in Hospice: 4
Total Daily Staff: 84
Waking Staff: 63
Inspection Report — Jul 7, 2023
Complaint Investigation
Date: Jul 7, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation at the facility.
Complaint Details
The inspection was complaint-related and the findings indicate no deficiencies were found, implying no substantiated violations.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Residents Served: 41
Current Hospice Residents: 4
Total Daily Staff: 90
Waking Staff: 68
Residents with Mobility Need: 49
Residents 60 Years or Older: 41
Inspection Report — Apr 12, 2023
Complaint Investigation
Date: Apr 12, 2023
Visit Reason
The inspection was conducted as a partial, unannounced visit due to a complaint and incident.
Complaint Details
The inspection was complaint-related and included an incident; no deficiencies or citations were found.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Current Hospice Residents: 5
Staffing: 62
Staffing: 47
Residents Age 60 or Older: 30
Residents with Mobility Need: 31
Inspection Report — Nov 7, 2022
Complaint Investigation
Date: Nov 7, 2022
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received by the Pennsylvania Department of Human Services.
Complaint Details
The visit was complaint-related. The plan of correction was accepted and fully implemented by the follow-up date.
Findings
The submitted plan of correction related to a medication administration violation was found to be fully implemented. The facility was required to maintain continued compliance.
Citations (1)
Resident #1 had an order for gabapentin 300mg once daily for 3 days, but the medication was given twice daily.
Report Facts
Residents Served: 31
Current Residents in Hospice: 5
Total Daily Staff: 62
Waking Staff: 47
Inspection Report — Sep 15, 2022
Complaint Investigation
Date: Sep 15, 2022
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 09/15/2022 and an exit conference on 09/16/2022.
Complaint Details
The inspection was complaint-related, but no deficiencies or substantiation status were noted.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Resident Support Staff: 36
Total Daily Staff: 108
Waking Staff: 81
Residents Served: 36
Current Residents in Hospice: 7
Residents 60 Years or Older: 35
Residents with Mobility Need: 36
Inspection Report — Jul 12, 2022
Routine
Date: Jul 12, 2022
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
| Name | Title | Context |
|---|---|---|
| Michele Moskalczyk | Human Services Licensing Supervisor | Signed the inspection report. |
Inspection Report — Jun 7, 2022
Renewal
Date: Jun 7, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license, with an unannounced full inspection on 06/07/2022 and exit conference on 06/08/2022.
Findings
The submitted plan of correction was determined to be fully implemented following the inspection. Deficiencies related to medical evaluation documentation, medication storage and availability, and support plan elements were identified and corrected prior to the exit interview.
Citations (3)
Resident #1 medical evaluation did not indicate the resident's height.
Resident #2 was prescribed Mucinex ER 600mg as needed, but the medication was not available in the home on 6/8/22.
Resident #1 support plan did not address a plan to meet, frequency or responsible party for the resident's diagnosis.
Report Facts
Residents Served: 38
Current Hospice Residents: 4
Resident Support Staff Hours: 38
Total Daily Staff: 114
Waking Staff: 86
Inspection Report — Mar 10, 2022
Complaint Investigation
Date: Mar 10, 2022
Visit Reason
The inspection was conducted as a complaint and incident investigation with unannounced partial inspections on 03/10/2022 and 03/30/2022.
Complaint Details
The visit was complaint-related involving an incident where Resident #1 kicked Resident #2 resulting in injury. The plan of correction was accepted and fully implemented.
Findings
A resident incident occurred where Resident #1 kicked Resident #2, causing Resident #2 to fall and sustain a head injury and a fractured pinky. The facility implemented a plan of correction including moving residents to separate rooms and staff inservice training on resident care.
Citations (1)
A resident was physically abused when Resident #1 kicked Resident #2 causing injury.
Report Facts
Residents Served: 38
Current Residents in Hospice: 5
Total Daily Staff: 76
Waking Staff: 57
Inspection Report — Oct 25, 2021
Routine
Date: Oct 25, 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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michele Moskalczyk | Human Services Licensing Supervisor | Signed the inspection report. |
Inspection Report — Sep 9, 2021
Routine
Date: Sep 9, 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 or deficiencies were identified as a result of this inspection.
Notice — Jun 30, 2021
Date: Jun 30, 2021
Visit Reason
The document serves as a renewal notification and license issuance for the Personal Care Home 'Elmcroft of Mid Valley' following receipt of the renewal application. It also advises that an annual onsite inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document; it is a license renewal notice confirming the issuance of a regular license and informing the facility of upcoming annual inspections.
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 26, 2021
Renewal
Date: May 26, 2021
Visit Reason
The inspection was conducted as a renewal visit with an incident reason, to review compliance and licensing status of the facility.
Findings
The inspection found several deficiencies including a confidentiality breach with resident records, combustible materials stored near heat sources, medication administration errors related to hold orders, and missing conspicuous posting of exit codes on locked doors. Plans of correction were accepted and implemented with staff training and ongoing monitoring.
Citations (4)
Resident records were posted with the privacy page still attached, violating confidentiality requirements.
Several socks were found in the laundry room behind the dryer on the exhaust vent, violating combustible storage rules.
Medication record showed medication administered when resident's pulse was less than the hold order threshold, indicating improper medication administration.
Locked exit door in the C-wing hallway did not have the exit code posted conspicuously by the exit door.
Report Facts
Residents Served: 29
Staffing Hours: 59
Waking Staff: 44
Current Hospice Residents: 2
Residents with Mobility Need: 30
Inspection Report — Mar 11, 2021
Renewal
Date: Mar 11, 2021
Visit Reason
The inspection was conducted as part of licensing inspections on multiple dates in March 2021 to assess regulatory compliance of the facility.
Findings
No regulatory citations or deficiencies were identified as a result of the inspections conducted on 03/11/2021, 03/12/2021, 03/26/2021, and 03/29/2021.
Inspection Report — Feb 8, 2021
Routine
Date: Feb 8, 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 — Jan 20, 2021
Date: Jan 20, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 01/20/2021, 01/21/2021, and 01/25/2021.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report — Dec 30, 2020
Routine
Date: Dec 30, 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 — Oct 20, 2020
Routine
Date: Oct 20, 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.
Inspection Report — Sep 23, 2020
Renewal
Date: Sep 23, 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 — Jul 15, 2020
Routine
Date: Jul 15, 2020
Visit Reason
The inspection was a licensing inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 07/15/2020.
Findings
No regulatory citations were identified as a result of this inspection.
Notice — May 5, 2020
Date: May 5, 2020
Visit Reason
The document serves as a renewal notification for the operation license of Elmcroft of Mid Valley Personal Care Home and informs that an annual onsite inspection will be conducted within the next twelve months.
Findings
No inspection findings are reported in this document; it is a license renewal and certificate of compliance issuance.
Inspection Report — Mar 20, 2020
Follow-Up
Date: Mar 20, 2020
Visit Reason
The visit was a follow-up review to verify that the previously submitted plan of correction was fully implemented.
Findings
The plan of correction related to an abuse incident was found to be fully implemented. Continued compliance must be maintained.
Citations (1)
42b - Abuse regulation 2600.42.b prohibits neglect, intimidation, physical or verbal abuse, mistreatment, or corporal punishment. Resident 1 was bitten on the left hand by Resident 2 causing injury treated by a doctor with antibiotics, tetanus shot, and band-aid.
Report Facts
Current Hospice Residents: 1
Memory Care Unit Residents Served: 41
Residents Who Have Mobility Need: 41
Residents Who Are 60 Years of Age or Older: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Barbara Kelly | Executive Director | Signed plan of correction and named in report |
Inspection Report — Jul 17, 2019
Annual Inspection
Date: Jul 17, 2019
Visit Reason
The visit was the Department’s Bureau of Human Services Licensing annual inspection of the facility to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Findings
The facility was found to be in compliance with the applicable regulations, and a regular license is being issued.
Notice — Mar 28, 2019
Date: Mar 28, 2019
Visit Reason
This document serves as a renewal certificate and letter confirming the renewal application for the Personal Care Home license of Elmcroft of Mid Valley. It notifies the facility that the Department will conduct an annual onsite inspection within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It only confirms the issuance of a regular license following the renewal application.
Report Facts
Inspection Report — Jun 13, 2018
Original Licensing
Date: Jun 13, 2018
Visit Reason
The inspection was conducted due to a change in legal entity and to assess compliance for a new license for Elmcroft of Mid Valley Personal Care Home.
Findings
The facility was found to be in substantial compliance with regulations but had two violations: missing labels on carbon monoxide detector batteries and water on the bathroom floor creating a slipping hazard. Plans of correction were submitted and partially implemented.
Citations (2)
55 Pa.Code §2600: The home was not in compliance with carbon monoxide alarm standards as batteries were not labeled with installation dates. The carbon monoxide detector in the hallway lacked a label indicating battery installation date.
55 Pa.Code §2600.88(a): The bathroom floor in bedroom B-4 had water between the shower stall and toilet creating a slipping hazard. The maintenance director removed the water during inspection.
Report Facts
Number of Residents Served: 41
Number of Current Hospice Residents: 3
Number of Hospice Residents in past year: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Barbara Kelly | Executive Director | Signed plan of correction for violations |
| Gerald Dumas | Department representative on-site during inspection | |
| Duane Valence | Department representative on-site during inspection |
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