Deficiencies per Year
12
9
6
3
0
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 75
Capacity: 85
Deficiencies: 0
Aug 28, 2025
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial inspection visit.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Report Facts
License Capacity: 85
Residents Served: 75
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 20
Current Hospice Residents: 15
Residents Age 60 or Older: 75
Residents with Mobility Need: 32
Inspection Report
Renewal
Census: 72
Capacity: 85
Deficiencies: 3
Jun 25, 2025
Visit Reason
The inspection was conducted as a full, unannounced visit for renewal, complaint, and incident reasons at Celebration Villa of Chippewa on 06/25/2025 and 06/26/2025.
Findings
The submitted plan of correction was determined to be fully implemented. Deficiencies were found related to emergency telephone numbers not posted in the secured dementia care unit, improper food storage with an unsealed container of chicken nuggets, and failure to follow prescriber's orders for medication administration. Corrective actions, staff training, and ongoing audits were implemented with proposed completion dates ranging from 07/30/2025 to 08/15/2025.
Deficiencies (3)
| Description |
|---|
| Telephone numbers for emergency management and personal care home complaint hotline were not posted nearby the telephone with an outside line in the secured dementia care unit kitchen. |
| An opened container of chicken nuggets was unsealed in the double freezer of the main kitchen. |
| Resident #1 was prescribed Levothyroxine 50mcg daily but the medication was not administered on June 2 and June 3, 2025 due to unavailability. |
Report Facts
License Capacity: 85
Residents Served: 72
Residents in Secured Dementia Care Unit: 19
Hospice Residents: 27
Residents with Mobility Need: 32
Total Daily Staff: 104
Waking Staff: 78
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Executive Director | Named in multiple findings and responsible for training and monitoring corrective actions |
| Dining Director | Director of Dining Services | Named in food storage deficiency and responsible for disposal of unsealed food and monitoring kitchenette areas |
| Memory Care Coordinator | Memory Care Coordinator | Placed emergency numbers on telephone and involved in training and audits |
| Resident Care Coordinator | Resident Care Coordinator | Involved in training and audits related to deficiencies |
| Maintenance Director | Maintenance Director | Responsible for monitoring emergency phone number tags |
| Life Enrichment Director | Life Enrichment Director | Participated in training and audits |
| Sales Director | Sales Director | Participated in training and audits |
| Director of Nursing | Director of Nursing | Conducts medication audits |
| Assistant Director of Nursing | Assistant Director of Nursing | Conducts medication audits |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 85
Deficiencies: 0
May 20, 2024
Visit Reason
The inspection was conducted as a complaint investigation at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related; however, no deficiencies were found and follow-up was not required.
Report Facts
Total Daily Staff: 104
Waking Staff: 78
Residents Served: 70
License Capacity: 85
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 18
Hospice Current Residents: 20
Residents with Mobility Need: 34
Residents with Physical Disability: 1
Residents 60 Years of Age or Older: 70
Inspection Report
Renewal
Census: 69
Capacity: 85
Deficiencies: 5
Apr 25, 2024
Visit Reason
The inspection was conducted as a renewal licensing inspection with an incident review for Celebration Villa of Chippewa on April 25 and 26, 2024.
Findings
The facility was found to be in compliance with 55 Pa. Code Ch. 2600 after corrections were made. Several deficiencies were identified related to training records, combustible materials accessibility, medication administration, and support plan documentation, all of which were corrected with plans of correction implemented by August 2, 2024.
Deficiencies (5)
| Description |
|---|
| The home's records of direct care staff training did not indicate the length of each course. |
| A 4 ounce bottle of Skin Prep alcohol spray labeled 'Flammable' was unsecured, unattended and accessible in the Memory Care kitchenette. |
| Resident #1 was administered incorrect doses of Humalog insulin not following prescriber's sliding scale orders. |
| Resident #3's support plan did not document how moderate supervision needs would be met. |
| Resident #1's July 2024 medication administration record lacked staff initials for medication administration on specific dates. |
Report Facts
License Capacity: 85
Residents Served: 69
Secured Dementia Care Unit Capacity: 20
Residents Served in Dementia Unit: 19
Staffing Hours: 108
Waking Staff: 81
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed the licensing letter and certificate of compliance. |
| Executive Director | Named in multiple findings and trainings related to deficiencies and plans of correction. | |
| Director of Nursing | DON | Named in multiple findings and trainings related to deficiencies and plans of correction. |
Inspection Report
Renewal
Census: 69
Capacity: 85
Deficiencies: 5
Apr 25, 2024
Visit Reason
The inspection was conducted as a renewal licensing inspection with an incident review for Celebration Villa of Chippewa on April 25 and 26, 2024.
Findings
The facility was found to be in compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes after corrections were made. Several deficiencies were identified related to training records, combustible materials accessibility, medication administration, and support plan documentation, all of which were corrected with plans of correction implemented by August 2, 2024.
Deficiencies (5)
| Description |
|---|
| The home's records of direct care staff training did not indicate the length of each course. |
| A 4 ounce bottle of Skin Prep alcohol spray labeled 'Flammable' was unsecured, unattended and accessible in the Memory Care kitchenette. |
| Resident #1 was administered incorrect doses of Humalog insulin not following prescriber's sliding scale orders. |
| Resident #3's support plan did not document how a moderate need for supervision would be met. |
| Resident #1's July 2024 medication administration record lacked initials of staff who administered medications on specific dates. |
Report Facts
License Capacity: 85
Residents Served: 69
Secured Dementia Care Unit Capacity: 20
Residents Served in Secure Dementia Care Unit: 19
Total Daily Staff: 108
Waking Staff: 81
Deficiencies cited: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed the licensing letter and certificate of compliance. |
Notice
Deficiencies: 0
Jan 17, 2024
Visit Reason
This letter responds 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 determined 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, satisfying regulatory requirements around resident privacy.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Director, Bureau of Human Services Licensing | Signed the letter responding to the facility's request regarding the Safely You Falls Management Program. |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 85
Deficiencies: 3
Jul 11, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation with unannounced partial inspections on multiple dates including July 11, 2023, and October 11, 2023.
Findings
The facility was found to have violations related to failure to report incidents timely, inadequate fall risk assessments and support plans, and neglect leading to resident falls and injuries. The facility received a provisional license due to these violations and submitted plans of correction which were not fully implemented as of December 6, 2023.
Complaint Details
The complaint investigation found substantiated neglect and inadequate care related to resident falls, failure to update care plans, and failure to report incidents. The resident suffered multiple falls, injuries, and eventual death with findings indicating neglect and abuse.
Deficiencies (3)
| Description |
|---|
| Failure to report an unwitnessed resident fall to the Department within 24 hours. |
| Resident's assessment and support plan did not address fall risk or indicate support to meet this need despite multiple medical assessments indicating high fall risk. |
| Resident was neglected resulting in multiple unwitnessed falls, injuries, and inadequate supervision including failure of bed alarm to sound. |
Report Facts
License Capacity: 85
Residents Served: 71
Residents Served: 73
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 20
Total Daily Staff: 108
Waking Staff: 81
Total Daily Staff: 107
Waking Staff: 80
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed the letter regarding the provisional license and enforcement action. |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 85
Deficiencies: 3
Jul 11, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation following reports of violations at Celebration Villa of Chippewa.
Findings
The inspection found violations related to failure to report incidents timely, inadequate fall risk assessments and support plans, and neglect/abuse of a resident resulting in multiple falls and injuries. Plans of correction were submitted but noted as not implemented as of December 6, 2023.
Complaint Details
The visit was complaint-related and incident-driven, investigating allegations of neglect and abuse of a resident with a history of falls and inadequate care plans. The complaint was substantiated based on the findings.
Deficiencies (3)
| Description |
|---|
| Failure to report an unwitnessed fall incident to the Department within 24 hours. |
| Resident's assessment and support plan did not address fall risk or indicate support to meet this need despite multiple medical assessments. |
| Resident was neglected and physically abused, including failure to maintain bed alarm and supervision, resulting in falls and injuries. |
Report Facts
License Capacity: 85
Residents Served: 71
Secured Dementia Care Unit Capacity: 20
Residents Served in Secure Dementia Care Unit: 20
Total Daily Staff: 108
Waking Staff: 81
Inspection Report
Renewal
Census: 69
Capacity: 85
Deficiencies: 4
Apr 4, 2023
Visit Reason
The inspection was conducted as a renewal visit for the facility, as indicated by the reason 'Renewal' and the unannounced full inspection on 04/04/2023 and 04/05/2023.
Findings
The inspection identified several deficiencies related to facility maintenance including damaged drywall in a bathroom, missing and improperly marked exit signs, and missing posted code for a locking mechanism. All deficiencies were corrected on the day of inspection or shortly thereafter, with ongoing monthly maintenance checklists implemented to ensure continued compliance.
Deficiencies (4)
| Description |
|---|
| Damaged drywall in the single use common bathroom near the shower exposing metal corner bead. |
| Missing exit sign on the gate in the courtyard connected to the secured dementia care unit. |
| Exit signs did not indicate direction to travel in two hallway locations. |
| No code posted for the locking mechanism on the gate in the courtyard connected to the secured dementia care unit. |
Report Facts
Residents Served: 69
License Capacity: 85
Residents Served in Secured Dementia Care Unit: 19
Current Hospice Residents: 28
Residents with Mobility Need: 30
Residents 60 Years or Older: 69
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named as responsible for correcting deficiencies such as drywall repair, exit sign replacement, and posting locking mechanism code. | |
| Administrator | Responsible for monthly checks and documentation of maintenance issues. |
Inspection Report
Census: 69
Capacity: 85
Deficiencies: 0
Dec 21, 2022
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
License Capacity: 85
Residents Served: 69
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 20
Hospice Current Residents: 23
Residents Age 60 or Older: 69
Residents with Mobility Need: 37
Resident Support Staff: 0
Total Daily Staff: 106
Waking Staff: 80
Inspection Report
Routine
Deficiencies: 0
Oct 18, 2022
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 10/18/2022.
Findings
No regulatory citations were identified as a result of this licensing inspection.
Inspection Report
Follow-Up
Census: 49
Capacity: 85
Deficiencies: 3
Jun 6, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the plan of correction related to uncovered trash receptacles and medication record discrepancies. Quality assurance trainings and ongoing audits were established to maintain compliance.
Deficiencies (3)
| Description |
|---|
| Uncovered metal trash can in the shared resident bathroom between resident rooms 206 and 208. |
| Medication Administration Record (MAR) indicated incorrect medication timing for Resident #1 (every four hours instead of every six hours). |
| Medications for Resident #2 were not administered as prescribed due to unavailability in the home. |
Report Facts
License Capacity: 85
Residents Served: 49
Memory Care Capacity: 20
Memory Care Residents Served: 17
Hospice Residents: 15
Residents with Mobility Need: 24
Total Daily Staff: 73
Waking Staff: 55
Medication Audits Frequency: 5
Inspection Report
Renewal
Census: 46
Capacity: 85
Deficiencies: 12
Dec 14, 2021
Visit Reason
The inspection was conducted as a renewal and complaint investigation visit to assess compliance with licensing regulations and to review submitted plans of correction.
Findings
Multiple deficiencies were identified including improper placement and operation of carbon monoxide detectors, failure to provide written notice of home rule changes to residents, unlabeled poisonous materials, sanitary condition issues, inadequate bathroom ventilation, missing toilet paper, improper refrigerator temperatures, incomplete medical evaluations, medication record errors, and missing emergency telephone numbers. Plans of correction were accepted and implemented for all deficiencies.
Deficiencies (12)
| Description |
|---|
| Carbon monoxide detectors were improperly placed and not operable near fossil fuel burning devices. |
| Residents were not properly informed in writing of changes to home smoking rules. |
| Unlabeled poisonous materials found in cleaning supply closets. |
| No sanitary means of hand drying in common bathroom in secured dementia care unit (SDCU). |
| Trash receptacles in kitchen and bathrooms were uncovered or missing lids. |
| Multiple bathrooms lacked operable windows or exhaust fans for ventilation. |
| No toilet paper available in common bathroom in SDCU. |
| Refrigerator temperature in SDCU kitchen exceeded required limits. |
| Resident medical evaluation forms incomplete, missing ability to self-administer medications. |
| Medication administration records missing dosage form, dose, route, frequency, and diagnosis/purpose for resident medications. |
| Preadmission screening forms incomplete, missing date, signature, and admitting home name. |
| Emergency telephone numbers not posted in resident bedrooms. |
Report Facts
License Capacity: 85
Residents Served: 46
Residents Served in Secured Dementia Care Unit: 18
Current Hospice Residents: 13
Total Daily Staff: 71
Waking Staff: 53
Deficiency Completion Dates: 12
Notice
Capacity: 85
Deficiencies: 0
Oct 4, 2021
Visit Reason
The document serves as a renewal notification and issuance of a regular license for the Personal Care Home 'Elmcroft of Chippewa' following receipt of the renewal application dated September 30, 2021.
Findings
No inspection findings are reported in this document; it advises that an onsite inspection will be conducted within the next twelve months as required by regulation.
Report Facts
Maximum capacity: 85
Secure Dementia Care Unit capacity: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
Inspection Report
Complaint Investigation
Census: 47
Capacity: 85
Deficiencies: 4
Jul 19, 2021
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection of the facility on 07/19/2021.
Findings
The inspection identified multiple deficiencies including insufficient personal care service hours during waking hours, inadequate staffing to meet residents' mobility needs especially during night shifts, inaccurate mobility assessments for residents, and incomplete directions for key-locking devices on secured dementia care unit exits. Plans of correction were accepted for all deficiencies.
Complaint Details
The inspection was triggered by a complaint as indicated by the inspection reason and was conducted as an unannounced partial inspection on 07/19/2021.
Deficiencies (4)
| Description |
|---|
| At least 75% of personal care service hours were not provided during waking hours; only 49.32 hours were provided instead of the required 53.25 hours. |
| Staffing was insufficient between 11:00 p.m. and 7:00 a.m. to meet residents' needs for personal care, supervision, and safe evacuation, especially for residents requiring two staff for evacuation. |
| Resident #1's mobility assessment was inaccurate, indicating minimal needs while requiring assistance of two staff persons for transferring. |
| Directions for operating magnetic lock releases on secured dementia care unit exits were incomplete, missing the inclusion of the 'star' key in the access code sequence. |
Report Facts
Residents served: 47
License capacity: 85
Residents with mobility needs: 26
Required direct care hours during waking hours: 53.25
Actual direct care hours during waking hours: 49.32
Staff scheduled between 11:00 p.m. and 7:00 a.m.: 2
Residents requiring 2 staff for evacuation: 5
Inspection Report
Complaint Investigation
Census: 44
Capacity: 85
Deficiencies: 2
May 6, 2021
Visit Reason
The inspection was conducted as a complaint investigation following allegations of abuse/neglect related to an incident involving Resident #1 on 04/14/2021.
Findings
The investigation found that Resident #1, who required assistance with bathing, was left unattended while showering, resulting in a fall causing a serious injury (a left displaced and depressed tibial plateau fracture). The facility failed to report the incident to the Department within the required 24-hour timeframe. The administrator submitted a state reportable on 05/08/2021 and implemented corrective actions including staff training and monitoring.
Complaint Details
The complaint investigation was substantiated. Resident #1 was found to have been neglected, resulting in a serious injury from a fall in the shower. The facility delayed reporting the incident to the Department until 05/08/2021, although the incident occurred on 04/14/2021.
Deficiencies (2)
| Description |
|---|
| Failure to report an incident or condition to the Department within 24 hours as required by regulation (16c - Written Incident Report). |
| Resident neglect resulting in a serious injury due to lack of supervision during showering (42b - Abuse). |
Report Facts
Residents served: 44
License capacity: 85
Current hospice residents: 5
Secured dementia care unit capacity: 20
Residents served in secured dementia care unit: 9
Residents aged 60 or older: 44
Residents with mobility need: 14
Inspection Report
Complaint Investigation
Census: 43
Capacity: 85
Deficiencies: 0
Apr 26, 2021
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection of the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was triggered by a complaint, but no deficiencies or regulatory citations were substantiated.
Report Facts
Residents Served: 43
License Capacity: 85
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 17
Hospice Current Residents: 9
Total Daily Staff: 63
Waking Staff: 47
Inspection Report
Complaint Investigation
Census: 44
Capacity: 85
Deficiencies: 1
Feb 24, 2021
Visit Reason
The inspection was conducted as a complaint investigation following an incident involving a resident eloping from the facility and sustaining injuries.
Findings
The facility failed to reactivate the front door alarm after it was disengaged for ambulance entry, resulting in a resident eloping and suffering hypothermia and injuries. The facility implemented a plan of correction including staff retraining, ongoing monitoring, and enhanced door alarm procedures.
Complaint Details
The complaint was substantiated based on the finding that the facility did not reactivate the door alarm, resulting in resident #1 eloping and sustaining hypothermia and injuries.
Deficiencies (1)
| Description |
|---|
| Failure to reactivate the front door alarm leading to resident elopement and injury. |
Report Facts
Residents Served: 44
License Capacity: 85
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 15
Hospice Current Residents: 4
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 15
Residents Age 60 or Older: 44
Inspection Report
Complaint Investigation
Census: 46
Capacity: 85
Deficiencies: 0
Feb 17, 2021
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection of the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was triggered by a complaint, but no substantiation or deficiencies were noted.
Report Facts
Residents Served: 46
License Capacity: 85
Memory Care Capacity: 20
Memory Care Residents Served: 16
Hospice Current Residents: 10
Total Daily Staff: 62
Waking Staff: 47
Inspection Report
Renewal
Deficiencies: 0
Jan 22, 2021
Visit Reason
The inspection visits on 01/22/2021, 03/09/2021, 03/24/2021, and 03/29/2021 were conducted as part of the Pennsylvania Department of Human Services licensing inspections for the facility.
Findings
No regulatory citations were identified as a result of these inspections.
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