15 Reports
Inspection Report — Apr 21, 2026
Renewal
Date: Apr 21, 2026
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements for Celebration Villa of Lebanon.
Findings
The facility was found to have multiple deficiencies including unsigned resident contracts, lack of CPR-trained staff during a night shift, hot water temperatures exceeding allowed limits, incorrect medication labeling, and incomplete training records. All deficiencies had plans of correction accepted and were implemented by early June 2026.
Citations (5)
2600.25b The resident-home contract for Resident #1 was not signed by the resident.
2600.63a On 4/12/26, approximately 42 residents were present with no staff certified in first aid/CPR during the night shift.
2600.89b Hot water temperatures in multiple bathroom and pantry sinks exceeded 120°F, measuring up to 124.3°F on 4/22/26.
2600.184a Resident #2's medication label incorrectly stated dosage as twice daily instead of once daily.
2600.190c The medication administration training record dated 10/19/25 lacked signatures and dates of trainer and student.
Report Facts
Residents served: 50
Current Hospice Residents: 5
Residents present during CPR deficiency: 42
Hot water temperature: 124.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member A | Medication Staff | Named in medication administration training record deficiency |
| Director of Nursing | Named in multiple findings including CPR training, medication labeling, and training record deficiencies | |
| Interim Executive Director | Named in multiple findings and training activities | |
| Resident Care Coordinator | Named in medication labeling deficiency and training | |
| Maintenance Director | Named in hot water temperature deficiency and corrective actions |
Notice — Nov 19, 2024
Date: Nov 19, 2024
Visit Reason
The document is a response to a waiver request to allow unlicensed direct care staff to administer subcutaneous injections of GLP-1 agonist medications by waiving specific medication administration training requirements.
Findings
The waiver outlines training requirements for direct care staff administering GLP-1 agonist injections, including completion of a Department-approved medication administration course, in-person training by licensed health professionals, and annual training hours related to GLP-1 medications and diabetes management. The facility must implement policies for administration, monitoring, documentation, and have a clinical contact available at all times.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Inspection Report — Oct 22, 2024
Plan of Correction
Date: Oct 22, 2024
Visit Reason
The inspection was conducted as a full, unannounced visit for renewal, complaint, and incident reasons on 10/22/2024 and 10/23/2024, with follow-up reviews including a plan of correction submission.
Findings
The report found repeated violations related to annual medical evaluations and medication storage. The facility submitted a plan of correction which was accepted and fully implemented by 12/17/2024, with ongoing audits and staff re-education planned.
Citations (2)
Resident medical evaluations were not completed annually as required, constituting a repeated violation.
Loose blue half-tablet found in medication cart; medication blister was punctured and taped over.
Report Facts
Residents Served: 53
Current Hospice Residents: 7
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 2
Residents with Physical Disability: 3
Residents Age 60 or Older: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator involved in review and re-education related to deficiencies | |
| Director of Nursing | Director of Nursing involved in review, re-education, and ongoing audits | |
| Resident Care Coordinator | Resident Care Coordinator involved in review, re-education, and ongoing audits | |
| Lead Med Tech | Lead Med Tech destroyed loose medication tablet during correction | |
| Med Tech | Med Tech assisted in destruction of loose medication tablet |
Notice — Mar 25, 2024
Date: Mar 25, 2024
Visit Reason
This letter responds to a request from the facility to use the TruLoo Smart Toilet seat to automate tracking of bowel movements and urinations to identify clinically concerning changes.
Findings
The Department reviewed the submitted information and found that the informed consent process includes voluntary participation, the right to discontinue use, and notification of residents' rights, satisfying regulatory privacy requirements.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Director, Bureau of Human Services Licensing | Signed the letter responding to the facility's request regarding the TruLoo Smart Toilet seat. |
Inspection Report — Nov 7, 2022
Complaint Investigation
Date: Nov 7, 2022
Visit Reason
The inspection was conducted as a complaint and incident investigation with an unannounced partial inspection on 11/07/2022 and 11/09/2022.
Complaint Details
The complaint investigation found that an incident of suspected abuse was reported but the Act 13 form was not submitted immediately. Staff notified the Director of Nursing and Administrator. The plan of correction included immediate submission of the form, posting of flow charts, and staff education. The plan was accepted on 11/28/2022 and implemented by 12/14/2022.
Findings
The submitted plan of correction was fully implemented and accepted. The main deficiency involved a delay in submitting an Act 13 form for suspected resident abuse, which was later corrected with staff education and process improvements.
Citations (1)
Failure to immediately submit an Act 13 form to the local Area Agency on Aging for a suspected resident abuse incident.
Report Facts
Total Daily Staff: 45
Waking Staff: 34
Residents Served: 42
Current Hospice Residents: 2
Residents Diagnosed with Mental Illness: 4
Residents Aged 60 or Older: 42
Residents with Mobility Need: 3
Residents with Physical Disability: 1
Inspection Report — Aug 16, 2022
Renewal
Date: Aug 16, 2022
Visit Reason
The inspection was conducted as a renewal and complaint investigation of Celebration Villa of Lebanon on 08/16/2022 and 08/17/2022.
Complaint Details
The inspection included a complaint investigation component as indicated by the reason for visit and follow-up on plan of correction submissions.
Findings
Multiple deficiencies were identified related to staff training, fire safety, poisonous material storage, medication management, and documentation. The facility submitted plans of correction which were determined to be fully implemented by the follow-up dates.
Citations (12)
Staff Member A and Staff Member B did not complete orientation in general fire safety and emergency preparedness prior to their first workday.
Staff Member A and Staff Member B did not complete orientation within 40 scheduled working hours including resident rights, emergency medical plan, and mandatory reporting of abuse and neglect.
Staff Member A and Staff Member B did not complete required initial direct care staff person training in multiple areas including safe management techniques and care of residents with dementia.
Three spray bottles of cleaner labeled 'Viking Disinfectant' were stored inside the dining area improperly.
The home did not have a recommended evacuation time designated in writing within the past year by a fire safety expert.
Signs stating smoking policy were not posted at the home's entrances.
Resident 3 had expired medication that was not discarded until discovered on 8/17/22.
Pharmacy label on Resident 1's medication did not include the dose of the medication.
Medication administration times and documentation for Residents 3 and 6 were inaccurate or inconsistent.
Medication administration records (MAR) for Residents 2 and 4 did not indicate diagnosis, dose, or purpose for medications.
Resident 3's medications were not administered per prescriber's orders and documentation was incomplete.
The home did not complete a preadmission screening form for Resident 3.
Report Facts
Residents Served: 51
Current Hospice Residents: 3
Total Daily Staff: 53
Waking Staff: 40
Deficiency Completion Dates: 9
Inspection Report — Sep 14, 2021
Renewal
Date: Sep 14, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing for the facility Elmcroft of Lebanon.
Findings
No regulatory citations were identified as a result of this inspection.
Notice — Jul 14, 2021
Date: Jul 14, 2021
Visit Reason
The document serves as a license renewal notification for Elmcroft of Lebanon Personal Care Home and informs that an annual inspection will be conducted within the next twelve months as required by regulation.
Findings
The letter confirms issuance of a regular license in response to the renewal application and advises that the Department will conduct an onsite inspection within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter. |
Inspection Report — Apr 8, 2021
Renewal
Date: Apr 8, 2021
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements at Elmcroft of Lebanon.
Findings
The submitted plan of correction was found to be fully implemented. Several deficiencies were identified related to hot water temperature, emergency management procedures, medical evaluations, storage procedures, and medication records, all of which had corrective plans accepted and implemented.
Citations (6)
Hot water temperature in areas accessible to residents exceeded 120°F, measuring 123 degrees Fahrenheit.
The home's written emergency procedures had not been reviewed or updated since 1/14/2020.
Medical evaluation for Resident #1 was incomplete, missing fields such as blood pressure, height, weight, pulse rate, temperature, and medical professional's name and license number.
The home failed to develop and implement procedures for safe storage, access, security, distribution, and use of medications and medical equipment by trained staff.
Medication administration record (MAR) for Resident #4 lacked diagnosis or purpose for the medication Sotalol HCL, which was administered twice daily.
Recorded blood sugar readings in medication administration records did not match glucometer readings for several residents.
Report Facts
Residents Served: 32
Current Hospice Residents: 4
Resident Support Staff: 0
Total Daily Staff: 34
Waking Staff: 26
Hot Water Temperature: 123
Medication MAR Reading: 244
Glucometer Reading: 215
Medication MAR Reading: 271
Glucometer Reading: 244
Medication MAR Reading: 227
Glucometer Reading: 223
Medication MAR Reading: 286
Inspection Report — Apr 14, 2020
Routine
Date: Apr 14, 2020
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Services Licensing.
Findings
The facility was found to be in compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Inspection Report — Mar 6, 2020
Routine
Date: Mar 6, 2020
Visit Reason
The Department’s Bureau of Human Services Licensing Representative conducted an inspection of the facility on March 6, 2020.
Findings
No regulatory citations with 55 Pa. Code Ch. 2600 relating to Personal Care Homes were identified as a result of this inspection.
Inspection Report — Jun 10, 2019
Renewal
Date: Jun 10, 2019
Visit Reason
The visit was a renewal licensing inspection conducted by the Department’s Bureau of Human Services Licensing to assess compliance with 55 Pa.Code Ch. 2600 for Personal Care Homes.
Findings
The inspection found violations related to staffing hours, specifically that the facility did not meet the required direct care service hours per resident and waking hours staffing requirements on specified dates. Plans of correction were submitted to address these deficiencies.
Citations (2)
Regulation 2600.57b requires at least 1 hour per day of direct care services per mobile resident. On 6/2/19 and 6/8/19, only 54.25 hours of direct care staffing was provided instead of the required 56 hours.
Regulation 2600.57d requires at least 75% of personal care service hours to be available during waking hours. On 6/2/19 and 6/8/19, only 40.75 hours were provided during waking hours, which is 73% of the required 42 hours.
Report Facts
Residents Served: 48
Current Hospice Residents: 2
Direct Care Hours Required: 56
Direct Care Hours Provided: 54.25
Waking Hours Direct Care Required: 42
Waking Hours Direct Care Provided: 40.75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Krista Funk | Executive Director | Named in plan of correction for staffing schedule review and ensuring staffing hours |
Notice — Apr 23, 2019
Date: Apr 23, 2019
Visit Reason
The document serves as a renewal notification for the Personal Care Home license and informs about the upcoming annual inspection required by state regulation.
Findings
No inspection findings are reported in this document. It confirms issuance of a regular license following the renewal application and notes a correction in the legal entity name on the license.
Inspection Report — Jun 14, 2018
Original Licensing
Date: Jun 14, 2018
Visit Reason
The inspection was conducted as a licensing inspection for a new legal entity operating a personal care home.
Findings
The facility was found to be in substantial compliance with applicable regulations, but the licensing inspector was unable to complete a full inspection due to the newness of the legal entity.
Notice — June 10, 2020
Date: June 10, 2020
Visit Reason
This document serves as a renewal notification and certificate of compliance for the Personal Care Home 'Elmcroft of Lebanon'. It informs the facility that an annual onsite inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It confirms issuance of a regular license following the renewal application.
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