Inspection Reports for Celebration Villa of Loyalsock
2985 4 Mile Dr Montoursville, PA, 17754, PA, 17754
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Renewal
Census: 44
Capacity: 90
Deficiencies: 2
Sep 10, 2025
Visit Reason
The inspection was conducted as a renewal visit to evaluate compliance with licensing requirements for Celebration Villa of Loyalsock.
Findings
The submitted plan of correction was found to be fully implemented. Two deficiencies were identified related to medication documentation errors and failure to follow prescriber's orders, both of which have corrective actions and ongoing monitoring in place.
Deficiencies (2)
| Description |
|---|
| Resident #1's blood glucose reading was incorrectly recorded on the medication administration record. |
| Resident #2's heart rate was not measured prior to administering medication as ordered. |
Report Facts
License Capacity: 90
Residents Served: 44
Current Hospice Residents: 3
Residents with Mental Illness: 1
Residents with Mobility Need: 8
Residents with Physical Disability: 1
Total Daily Staff: 52
Waking Staff: 39
Inspection Report
Renewal
Census: 48
Capacity: 90
Deficiencies: 3
Oct 24, 2024
Visit Reason
The inspection was conducted as a renewal review of the facility's compliance with licensing regulations.
Findings
The submitted plan of correction was found to be fully implemented. Deficiencies included lack of operable lamps at bedside, incomplete medical evaluations, and premature resident assessments, all of which were addressed with corrective actions and staff training.
Deficiencies (3)
| Description |
|---|
| Residents in rooms 13 and 120 did not have an operable lamp or other source of lighting that could be turned on at bedside. |
| Resident #1's most recent Documentation of Medical Evaluation was not signed by a physician. |
| Resident #2's assessment portion of the Resident Assessment and Support Plan was completed prior to the date of admission. |
Report Facts
Residents Served: 48
License Capacity: 90
Current Hospice Residents: 3
Total Daily Staff: 51
Waking Staff: 38
Inspection Report
Census: 46
Capacity: 90
Deficiencies: 0
Sep 29, 2022
Visit Reason
The inspection was conducted as a partial, unannounced licensing inspection due to an incident.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Resident Support Staff: 9
Total Daily Staff: 64
Waking Staff: 48
Residents Served: 46
License Capacity: 90
Current Hospice Residents: 1
Residents Age 60 or Older: 46
Residents with Mobility Need: 9
Inspection Report
Renewal
Census: 39
Capacity: 90
Deficiencies: 3
Jun 22, 2022
Visit Reason
The inspection was conducted as a renewal visit for the facility license.
Findings
The inspection identified deficiencies related to refrigerator/freezer temperatures exceeding required limits, fire drills being conducted on a predictable schedule, and incomplete resident record content regarding identifiable marks. Plans of correction were accepted and implemented with training and ongoing monitoring.
Deficiencies (3)
| Description |
|---|
| Refrigerators had temperature readings above 40°F, including the main kitchen Kalok refrigerator at 45°F, a small Continental refrigerator at 50°F, and a med room refrigerator at 46°F. |
| Fire drills were consistently conducted at the end of each month, indicating a pattern rather than varying days and times as required. |
| Resident records did not indicate if residents had any identifiable marks. |
Report Facts
License Capacity: 90
Residents Served: 39
Staffing Hours: 58
Waking Staff: 44
Hospice Residents: 1
Residents with Mobility Need: 19
Fire Drill Dates: 6
Inspection Report
Complaint Investigation
Census: 36
Capacity: 90
Deficiencies: 1
May 24, 2022
Visit Reason
The inspection was conducted as a complaint and incident investigation with an unannounced partial inspection on 05/24/2022 and an exit conference on 06/06/2022.
Findings
The inspection found medication administration errors where Resident 1's medications were given to Resident 2 in error on two occasions. Staff members involved were counseled and re-educated, and ongoing monitoring and training were implemented to prevent recurrence.
Complaint Details
The visit was complaint-related, investigating medication administration errors involving two residents and multiple staff members. The plan of correction was accepted and fully implemented.
Deficiencies (1)
| Description |
|---|
| Resident 1’s prescription of Tramadol was given to Resident 2 in error by Staff Member A on 4/9/2022, and Resident 1’s prescribed medication of Hydracodone was given to Resident 2 in error by Staff Member B on 4/13/2022. Pill cups with pills still in them were found in resident rooms on several occasions. |
Report Facts
License Capacity: 90
Residents Served: 36
Current Hospice Residents: 1
Residents 60 Years or Older: 36
Residents with Mobility Need: 9
Inspection Report
Renewal
Deficiencies: 0
Jan 11, 2022
Visit Reason
The inspection was conducted as part of the Pennsylvania Department of Human Services, Bureau of Human Service Licensing licensing inspections on 01/11/2022 and 01/13/2022 for the facility Celebration Villa of Loyalsock.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report
Renewal
Census: 32
Capacity: 90
Deficiencies: 9
Jun 29, 2021
Visit Reason
The inspection was a renewal visit conducted on 06/29/2021 and 06/30/2021 to review compliance with licensing requirements at Elmcroft of Loyalsock.
Findings
The inspection identified multiple deficiencies including outdated carbon monoxide detector batteries, incomplete staff fire safety orientation, outdated food storage, missing documentation of emergency procedure submission, incomplete medical evaluation forms for residents, and unsigned resident support plans. Plans of correction were accepted and documented as implemented with staff training completed.
Deficiencies (9)
| Description |
|---|
| Batteries in the carbon dioxide monitor in the lobby were last changed in February 2020 and must be replaced annually. |
| Staff person A was not trained in required fire safety and emergency preparedness topics on their first day of work. |
| Staff person B did not receive training on resident rights for the training year 2019; Staff person C did not receive fire safety training by a fire safety expert for 2019. |
| Four large dented cans (3 spaghetti sauce, 1 stewed tomatoes) were stored in the pantry and must not be used. |
| Emergency procedures were not documented as reviewed and submitted to the local emergency management agency in 2020 or 2021. |
| During a fire drill on 12/20/2019, one resident refused to leave their room. |
| Documentation of Medical Evaluation (DME) form for resident #1 was missing pulse rate; DME form for resident #2 was missing weight. |
| Support plan for resident #3 was not finalized within 30 days of admission. |
| Support plan for resident #1 was not signed by the resident or the person who completed the assessment. |
Report Facts
License Capacity: 90
Residents Served: 32
Dented Cans: 4
Staffing Hours: 42
Waking Staff: 32
Current Hospice Residents: 1
Residents with Mobility Need: 10
Residents 60 Years or Older: 32
Residents Diagnosed with Mental Illness: 1
Inspection Report
Renewal
Deficiencies: 0
Mar 30, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 03/30/2021 and 03/31/2021 for the facility.
Findings
No regulatory citations were identified as a result of this inspection.
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