Inspection Reports for Celebration Villa of Reedsville
55 Carriage House Ln Reedsville, PA, 17084, PA, 17084
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
10.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
123% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
10% occupied
Based on a May 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Census: 7
Capacity: 72
Deficiencies: 2
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.
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.
Complaint Details
The inspection was triggered by a complaint and incident as stated under Inspection Information Reason.
Deficiencies (2)
| Description |
|---|
| 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
License Capacity: 72
Residents Served: 41
Current Residents: 7
Direct Care Staff Annual Training Completion Date: Jun 30, 2025
Follow-Up Date: May 30, 2025
Inspection Report
Renewal
Census: 37
Capacity: 72
Deficiencies: 7
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.
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.
Complaint Details
The inspection included complaint investigation as part of the renewal process, but no specific substantiation status was stated.
Deficiencies (7)
| Description |
|---|
| 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
License Capacity: 72
Residents Served: 37
Total Daily Staff: 49
Waking Staff: 37
Residents with Mobility Need: 12
Current Hospice Residents: 1
Inspection Report
Renewal
Census: 36
Capacity: 72
Deficiencies: 0
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
License Capacity: 72
Current Hospice Residents: 5
Residents Age 60 or Older: 36
Residents with Mobility Need: 13
Residents with Physical Disability: 1
Inspection Report
Renewal
Census: 34
Capacity: 72
Deficiencies: 17
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.
Deficiencies (17)
| Description |
|---|
| 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
License Capacity: 72
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
Complaint Investigation
Census: 34
Capacity: 72
Deficiencies: 5
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.
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.
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.
Deficiencies (5)
| Description |
|---|
| 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
License Capacity: 72
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
Capacity: 72
Deficiencies: 0
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
Maximum capacity: 72
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
Inspection Report
Renewal
Census: 39
Capacity: 72
Deficiencies: 9
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.
Deficiencies (9)
| Description |
|---|
| 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
License Capacity: 72
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
Follow-Up
Census: 31
Capacity: 72
Deficiencies: 2
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.
Deficiencies (2)
| Description |
|---|
| 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
License Capacity: 72
Residents Served: 31
Total Daily Staff: 37
Waking Staff: 28
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