Inspection Reports for The Villa Personal Care LLC
429 NAPOLEON PLACE,, JOHNSTOWN, PA, 15901
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
4.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
2% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
50% occupied
Based on a March 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Census: 25
Capacity: 50
Deficiencies: 3
Date: Mar 4, 2025
Visit Reason
The inspection was conducted as a renewal visit to review the facility's compliance with licensing requirements.
Findings
The submitted plan of correction was found to be fully implemented. Deficiencies included safety risks related to assistive devices, lack of thermometer in the refrigerator/freezer, and unlocked prescription medication, all of which were corrected by the facility.
Deficiencies (3)
Resident with dementia had an enabler bar on bed that posed a safety risk as the resident could not cognitively use it.
Refrigerator/freezer in break room used to store resident bread did not have a thermometer.
Prescription medication labeled Hydrophilic Cream was unlocked, unattended, and accessible in a resident's room.
Report Facts
License Capacity: 50
Residents Served: 25
Current Residents Receiving Hospice: 4
Residents 60 Years or Older: 25
Residents with Physical Disability: 3
Total Daily Staff: 25
Waking Staff: 19
Inspection Report
Renewal
Census: 36
Capacity: 50
Deficiencies: 8
Date: Apr 9, 2024
Visit Reason
The inspection was conducted as a renewal inspection of THE VILLA PERSONAL CARE LLC to review compliance with licensing requirements.
Findings
The inspection identified several deficiencies including entrapment risks from bed enabler bars, issues with the wandergard locking system, incomplete evacuation during a fire drill, fire drills conducted during shift changes, incomplete medical evaluations, and medication storage and documentation issues. Plans of correction were accepted and implemented by April 26, 2024.
Deficiencies (8)
Bed enabler bars in rooms 208 and 210 pose an entrapment risk due to uncovered openings.
Wandergard devices caused the front door to lock when residents were near, preventing unobstructed egress.
During a fire drill on 6/5/23, only 36 of 37 residents were evacuated.
Two fire drills were conducted during shift change times when additional staff were present.
Resident #3's initial medical evaluation was completed more than 60 days prior to admission.
Sections 4 and 8 of Resident #1's medical evaluation were left blank.
Resident #2 and #3 had medical evaluations with previous evaluations not within required annual timeframe.
Resident #4's glucometer readings and insulin administration were not properly recorded on the Medication Administration Record (MAR).
Report Facts
License Capacity: 50
Residents Served: 36
Current Residents in Hospice: 5
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 12
Residents 60 Years or Older: 36
Residents Diagnosed with Intellectual Disability: 0
Residents with Physical Disability: 0
Residents Receiving Supplemental Security Income: 0
Residents Present for Fire Drill: 37
Residents Evacuated During Fire Drill: 36
Staff Present During Fire Drill on 8/15/23: 5
Staff Present During Fire Drill on 1/25/24: 6
Total Daily Staff: 48
Waking Staff: 36
Inspection Report
Census: 37
Capacity: 50
Deficiencies: 0
Date: Aug 31, 2023
Visit Reason
The inspection was conducted as a licensing inspection on 08/31/2023, triggered by an incident.
Findings
No regulatory citations or deficiencies were identified during this unannounced partial inspection.
Report Facts
Residents Served: 37
License Capacity: 50
Current Hospice Residents: 3
Resident Support Staff Hours: 0
Total Daily Staff Hours: 48
Waking Staff Hours: 36
Residents Age 60 or Older: 37
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 11
Inspection Report
Renewal
Census: 38
Capacity: 50
Deficiencies: 4
Date: Jan 26, 2023
Visit Reason
The inspection was conducted as a renewal inspection of THE VILLA PERSONAL CARE LLC to review compliance with licensing requirements.
Findings
The inspection identified several deficiencies related to medical evaluations, medication storage, expired medications, and availability of prescribed medications. The facility submitted a plan of correction which was determined to be fully implemented by the follow-up date.
Deficiencies (4)
Documentation of Medical Evaluation was not completed within 30 days after admission for Resident #1.
A medicine cup with medication was observed unlocked, unattended, and accessible at the front desk.
Expired acetaminophen prescribed for Resident #2 was found in the medication cart.
Medications prescribed for Residents #1, #2, and #3 were not available in the home.
Report Facts
License Capacity: 50
Residents Served: 38
Current Hospice Residents: 3
Residents Age 60 or Older: 38
Residents with Mobility Need: 9
Residents with Physical Disability: 1
Total Daily Staff: 47
Waking Staff: 35
Inspection Report
Renewal
Census: 30
Capacity: 50
Deficiencies: 4
Date: Jun 29, 2021
Visit Reason
The inspection was conducted as a full, unannounced visit for renewal and complaint reasons on 06/29/2021.
Findings
The submitted plan of correction was determined to be fully implemented. Deficiencies were identified related to staff qualifications, emergency telephone numbers, medication administration records, and preadmission screening forms, all of which were addressed with corrective actions and documented completion by 08/01/2021.
Deficiencies (4)
Direct Care Staff Person A does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry on file, as required.
There are no emergency telephone numbers that include the nearest hospital and fire department on or by the telephone in Resident Room #104, #207 and #303.
Resident 1 is prescribed medication every four hours while awake. The administration was not included on Resident 1's medication administration record (MAR) on 6/21/2021 nor is there a nurse's note regarding this issue.
Resident 3's preadmission screening form does not include a determination that the needs of the resident can be met by the services provided by the home.
Report Facts
License Capacity: 50
Residents Served: 30
Current Hospice Residents: 3
Residents Age 60 or Older: 30
Residents with Mobility Need: 12
Resident Support Staff: 23
Total Daily Staff: 65
Waking Staff: 49
Inspection Report
Renewal
Capacity: 50
Deficiencies: 0
Date: Jun 22, 2021
Visit Reason
The document is a renewal license issued in response to the facility's March 16, 2021 renewal application to operate The Villa Personal Care LLC pursuant to Title 55, PA Code, Chapter 2600. The Department advises that an onsite inspection will be conducted within the next twelve months as required by regulation.
Findings
The document does not report any inspection findings but confirms issuance of a regular license for the facility to operate as a Personal Care Home with a maximum capacity of 50 residents.
Report Facts
Maximum licensed capacity: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal license letter and certificate |
Notice
Deficiencies: 0
Date: Mar 19, 2021
Visit Reason
The document serves as a waiver approval for a direct care staff person at The Villa Personal Care LLC who was unable to complete nurse aide certification testing due to COVID restrictions at testing sites.
Findings
The waiver is granted under specific conditions including the expectation that the staff person will receive a general education diploma by July 31, 2021, and documentation will be maintained by the facility. The waiver is effective from March 19, 2021 to June 19, 2021.
Report Facts
Waiver effective dates: From March 19, 2021 to June 19, 2021
Expected diploma completion date: By July 31, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeanne Parisi | Director | Signed the waiver approval letter |
| Janel Phillips | Administrator | Recipient of the waiver approval letter |
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