Inspection Report
Enforcement
Census: 43
Capacity: 80
Deficiencies: 6
May 27, 2025
Visit Reason
The inspection was conducted due to an incident and licensing inspections on May 27 and May 29, 2025, resulting in violations of 55 Pa. Code Ch. 2600 related to Personal Care Homes.
Findings
Multiple violations were found including failure to meet resident care needs, inadequate staff qualifications, failure to provide certified CPR assistance during an emergency, incomplete medication records, and deficiencies in resident support plans. The facility's license was revoked and replaced with a first provisional license contingent on correction of violations.
Deficiencies (6)
| Description |
|---|
| Resident #1's support plan did not include a plan to meet service needs despite multiple falls and injuries. |
| Staff member A lacked a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| Staff member A, certified in obstructed airway techniques, failed to render assistance to resident #2 during an aspiration incident. |
| Resident #1's May 2025 medication administration record did not indicate the diagnosis or purpose for prescribed medications. |
| Resident #2's January 2025 medication administration record did not include the initials of the staff person who administered Nitroglycerin. |
| Resident #1's support plan did not document how medical, dental, vision, hearing, mental health or other behavioral care services needs would be met. |
Report Facts
License Capacity: 80
Residents Served: 43
Total Daily Staff: 58
Waking Staff: 44
Current Residents on Hospice: 7
Residents with Mobility Need: 15
Residents Diagnosed with Intellectual Disability: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Named in findings related to failure to provide CPR assistance during aspiration incident and lacking required qualifications. | |
| Juliet Marsala | Deputy Secretary, Office of Long-term Living | Signed enforcement and licensing correspondence. |
Inspection Report
Renewal
Census: 53
Capacity: 80
Deficiencies: 7
Oct 29, 2024
Visit Reason
The inspection was conducted as a renewal visit to review compliance and verify the submitted plan of correction was fully implemented.
Findings
The inspection identified multiple deficiencies including sanitary conditions, food storage violations, refrigerator/freezer temperature issues, emergency procedure submission delays, evacuation drill timing exceeding limits, medication cart errors, and incomplete preadmission screening forms. All deficiencies had plans of correction accepted and were implemented by December 9, 2024.
Deficiencies (7)
| Description |
|---|
| Pungent odor of urine detected in common bathroom near reception desk. |
| Cases of food and supplies stored on the floor in dry food storage area. |
| Freezer temperature in 200-hall kitchenette was above required temperature (2°F and 3°F). |
| Written emergency procedures had not been reviewed and submitted to local emergency management agency since 1/28/21. |
| Evacuation drill exceeded maximum safe evacuation time by 8 seconds. |
| Discontinued medication remained in medication cart after discontinuation date. |
| Resident's preadmission screening form lacked determination that needs could be met by the home. |
Report Facts
License Capacity: 80
Residents Served: 53
Freezer Temperature: 2
Freezer Temperature: 3
Evacuation Time: 908
Inspection Report
Complaint Investigation
Census: 44
Capacity: 80
Deficiencies: 0
Jun 5, 2024
Visit Reason
The inspection was conducted as a complaint investigation at the facility on 06/05/2024.
Findings
No regulatory citations or deficiencies were identified during this unannounced partial inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Report Facts
Total Daily Staff: 49
Waking Staff: 37
Residents Served: 44
License Capacity: 80
Current Hospice Residents: 10
Residents Age 60 or Older: 44
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 5
Inspection Report
Follow-Up
Census: 52
Capacity: 80
Deficiencies: 1
Feb 15, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident, with a focus on verifying the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the submitted plan of correction related to a confidentiality violation where resident records were left unattended and accessible in an unlocked office. Continued compliance is required.
Deficiencies (1)
| Description |
|---|
| Resident's Medication Administration Record (MAR) and additional resident information were unattended and accessible in the unlocked Executive Director's office. |
Report Facts
License Capacity: 80
Residents Served: 52
Current Hospice Residents: 12
Residents 60 Years or Older: 49
Residents Diagnosed with Intellectual Disability: 3
Residents with Mobility Need: 7
Total Daily Staff: 59
Waking Staff: 44
Inspection Report
Renewal
Census: 50
Capacity: 80
Deficiencies: 6
Oct 31, 2023
Visit Reason
The inspection was conducted as a renewal visit for the facility's license, including a full unannounced inspection on 10/31/2023 and a follow-up review of the submitted plan of correction.
Findings
The facility was found to have multiple deficiencies including contract rescission rights not included in resident contracts, compensation issues related to resident labor, uncovered trash receptacles, lack of bathroom ventilation, missing refrigerator thermometers, and loose pills found in medication carts. All deficiencies had plans of correction accepted and were implemented by 11/27/2023.
Deficiencies (6)
| Description |
|---|
| Resident contracts did not include the right to rescind the contract within 72 hours after the initial signature. |
| Resident was observed performing labor tasks without compensation. |
| Full, uncovered, unattended trash can in the kitchen. |
| Bathroom in bedroom 229 lacked operable window or ventilation fan. |
| No thermometer in the walk-in refrigerator located in the kitchen. |
| Three loose pills found in the 100 hall medication cart. |
Report Facts
License Capacity: 80
Residents Served: 50
Current Hospice Residents: 8
Residents 60 Years or Older: 50
Residents Diagnosed with Intellectual Disability: 3
Residents with Mobility Need: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Replaced kitchen trashcan and investigated bathroom ventilation issue | |
| Maintenance Director | Investigated and repaired bathroom ventilation fan and placed thermometer in refrigerator | |
| Director of Nursing | Removed loose pills from medication cart and involved in medication cart audits | |
| Assistant Director of Nursing | Involved in medication cart audits | |
| Administrator | Oversaw education and compliance with regulations and audits |
Inspection Report
Enforcement
Census: 55
Capacity: 80
Deficiencies: 4
May 31, 2023
Visit Reason
The inspection was conducted as an interim partial inspection with an unannounced notice to assess compliance and follow up on a plan of correction submission.
Findings
The facility was found to have multiple violations related to medication administration, including failure to report medication errors timely, incomplete medication records lacking diagnosis or purpose, failure to follow prescriber's orders, and failure to report medication errors to residents and prescribers. The Department revoked the certificate of compliance and issued a first provisional license with fines pending if violations are not corrected.
Severity Breakdown
Class II: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to report medication errors to the Department within 24 hours as required. | Class II |
| Medication administration records did not contain diagnosis or purpose of prescribed medications for multiple residents. | Class II |
| Failure to follow prescriber's orders, including not administering prescribed Vitamin D3 and blood sugar checks. | Class II |
| Failure to immediately report medication errors to the resident, designated person, and prescriber. | Class II |
Report Facts
License Capacity: 80
Residents Served: 55
Fine per violation per resident per day: 5
Calculated Fine per violation: 275
Mandated Correction Date: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Williams | Personal Care Home Administrator | Named as submitter of plan of correction and involved in oversight |
| Jason McCloskey | Lead Inspector | Conducted on-site inspection and reviewed plan of correction |
| Jennifer Brown | Regional Director of Operations | Added diagnoses to medication records during plan of correction |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 80
Deficiencies: 6
Mar 29, 2023
Visit Reason
The inspection was conducted as a complaint investigation following allegations related to medication errors, neglect, and abuse at Celebration Villa of Dillsburg.
Findings
The inspection found multiple violations including failure to administer prescribed medications, failure to report medication errors, neglect resulting in a resident's death due to misidentification and failure to provide CPR, unsecured medication cart, and unsigned resident contracts. The facility was issued a provisional license and fines were proposed pending correction.
Complaint Details
The complaint investigation substantiated neglect and abuse related to failure to provide CPR, medication errors, and failure to report these errors. The resident's death was linked to these failures.
Deficiencies (6)
| Description |
|---|
| Resident 1 was not given medications on multiple occasions because the medications were not available in the home, and these medication errors were not reported to the resident, designated person, or physician. |
| Resident-home contracts for Residents 1 and 2 were not signed by the residents. |
| Failure to provide CPR to Resident 1 during a medical emergency due to misidentification and failure to correctly identify DNR status. |
| Medication cart was found unlocked and unattended in a common area. |
| Resident 1 did not receive prescribed medications because they were not available in the home. |
| Medication errors were not immediately reported to the resident, designated person, or prescriber. |
Report Facts
License Capacity: 80
Residents Served: 49
Staffing Hours - Total Daily Staff: 55
Staffing Hours - Waking Staff: 41
Fines Proposed: 275
Census at Inspection: 55
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Williams | Personal Care Home Administrator | Named in relation to plan of correction submissions and oversight |
| Jason McCloskey | Lead Inspector | Conducted the complaint investigation inspection |
| Alex Shambach | Reviewer for enforcement document submission | |
| Staff person A | Licensed Practical Nurse | Failed to provide CPR to Resident 1 during medical emergency |
Inspection Report
Renewal
Census: 55
Capacity: 80
Deficiencies: 12
Nov 9, 2022
Visit Reason
The inspection was conducted as a renewal and complaint investigation visit to evaluate compliance with licensing requirements and complaint allegations.
Findings
The inspection identified multiple deficiencies including failure to report an incident to the Department, inadequate quality management reviews, incomplete fire safety orientation for staff, unclean kitchen surfaces, missing bedside furniture and lighting for a resident, incomplete fire drill records, lack of smoking signage, medication administration failures, insulin injections by untrained staff, and incomplete or unsigned resident support plans. Plans of correction were accepted and implemented by December 2022.
Deficiencies (12)
| Description |
|---|
| Failure to report a resident fall incident to the Department within 24 hours. |
| Only one quality management review held this year instead of monthly as required. |
| Staff person did not complete first day fire safety orientation. |
| Kitchen walls and trashcan lid were soiled with food and dried ketchup. |
| No bedside table or shelf beside Resident 7's bed. |
| Resident 7 did not have access to operable lamp or bedside lighting. |
| Fire drill records had '0' listed for evacuation time and exit routes on multiple dates. |
| No smoking signage posted near facility entrances despite being a designated smoking facility. |
| Medications were not administered to residents #2, #3, #4, and #5 on specified dates due to unavailability. |
| Staff person B administered insulin without completing required diabetes education within last 12 months. |
| Resident #6 eloped and support plan did not reflect supervision needs; residents #2 and #3 support plans incomplete. |
| Resident #2's support plan was not signed or dated by staff; Resident #3's support plan was not dated by resident. |
Report Facts
Residents Served: 55
License Capacity: 80
Current Hospice Residents: 7
Residents Age 60 or Older: 55
Residents with Intellectual Disability: 3
Residents with Mobility Need: 5
Total Daily Staff: 60
Waking Staff: 45
Inspection Report
Renewal
Capacity: 80
Deficiencies: 0
Jul 14, 2021
Visit Reason
The document is a renewal license issued in response to the April 20, 2021 renewal application to operate the Personal Care Home, Elmcroft of Dillsburg. The Department advises that an onsite inspection will be conducted within the next twelve months as required by regulation.
Findings
A regular license is being issued for the facility. The Department will conduct an inspection within the next twelve months and will take enforcement action if noncompliance is found.
Report Facts
Maximum capacity: 80
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal license letter |
Inspection Report
Renewal
Census: 40
Capacity: 80
Deficiencies: 6
May 24, 2021
Visit Reason
The inspection was conducted as a renewal and complaint investigation visit to assess compliance and address specific complaints.
Findings
The submitted plan of correction was determined to be fully implemented. Multiple deficiencies were identified related to resident contracts, fire safety orientation, first aid kit contents, medication administration records, resident assessments, and support plan signatures, all with corrective actions planned and completed by specified dates.
Complaint Details
The visit included a complaint investigation as part of the renewal inspection.
Deficiencies (6)
| Description |
|---|
| Resident #1's resident-home contract was not signed by the resident. |
| Staff Person A did not receive orientation in general fire safety and emergency preparedness on the first day of work. |
| The first aid kit in the 2020 Chevy Bus used to transport residents did not include a thermometer, tweezers, or eye coverings. |
| Resident #3's medication administration record showed a blood glucose level recorded without a glucometer reading. |
| Resident #1's initial assessment was not completed within 15 days of admission. |
| The RASP for Resident #1 and Resident #2 did not include all required signatures. |
Report Facts
License Capacity: 80
Residents Served: 40
Current Hospice Residents: 2
Residents Age 60 or Older: 40
Residents with Intellectual Disability: 3
Residents with Mobility Need: 30
Residents with Physical Disability: 0
Staff Total Daily: 70
Staff Waking: 53
Inspection Report
Renewal
Deficiencies: 0
Jan 27, 2021
Visit Reason
The inspection was conducted as part of the Pennsylvania Department of Human Services, Bureau of Human Service Licensing's licensing inspections of the facility.
Findings
No regulatory citations were identified as a result of this inspection.
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