Inspection Reports for
Celebration Villa of Lewisburg

No regulatory citations or deficiencies were identified during this inspection.

The inspection was triggered by a complaint. No deficiencies or regulatory citations were found, indicating no substantiated issues.

No regulatory citations or deficiencies were identified as a result of the inspections conducted on 04/23/2026 and 05/18/2026.

No regulatory citations or deficiencies were identified as a result of this inspection.

The facility was found to have multiple deficiencies including failure to report suspected abuse timely, use of mechanical restraints, inadequate staffing, medication errors, and incomplete support plans. Plans of correction were accepted with training and audits scheduled.

The visit was complaint-related, triggered by allegations of verbal abuse by staff person A towards a resident. The complaint was substantiated as staff member A was suspended and terminated following investigation.

The facility was found to have multiple deficiencies including failure to timely report resident abuse and incidents, verbal abuse of a resident by staff, blocked fire exits, unsafe smoking area conditions, unlocked medication carts, and missing resident documentation for secured dementia care unit admission. Corrective actions and ongoing training plans were implemented and accepted.

The inspection included complaint investigations related to inadequate assistance with activities of daily living, neglect, abuse, privacy violations, and staffing shortages. Specific substantiation status is not explicitly stated.

Multiple violations were found including issues with carbon monoxide detector maintenance, inadequate assistance with activities of daily living, abuse and neglect concerns, privacy violations, staffing shortages, training deficiencies, unsafe resident equipment, food safety, fire safety, medication security, and documentation errors. A provisional license was issued due to these violations.

The complaint involved a resident whose medications were found in their room on three occasions, and concerns about inadequate personal hygiene and feeding assistance were raised. The complaint was substantiated by staff interviews and investigation.

The inspection found deficiencies related to inadequate assistance with activities of daily living, improper medication administration, untimely additional resident assessments, and unsigned support plans. The facility submitted plans of correction which were accepted and later fully implemented.

The waiver outlines training requirements for direct care staff administering GLP-1 agonist injections, including successful completion of a Department-approved medication administration course, in-person training by licensed health care professionals, and annual training hours related to GLP-1 agonist medications and diabetes management. The facility must implement policies for administration, monitoring, documentation, and have a clinical contact available at all times.

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 a licensed health care professional, and annual training hours related to GLP-1 medications and diabetes management. The facility must have policies for administration, monitoring, documentation, and a clinical contact available at all times.

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 care 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.

The investigation found an alleged abuse incident involving a staff member and a resident, which was ultimately unsubstantiated. A plan of correction including staff retraining and ongoing supervision was accepted and implemented.

The Department reviewed the submitted information and found that informed consent procedures meet regulatory requirements for resident rights and privacy. The letter does not endorse the device but confirms compliance with privacy regulations if procedures are followed.

The inspection was complaint-related, but no deficiencies or citations were substantiated.

No regulatory citations or deficiencies were identified as a result of this inspection.

The visit was complaint-related, but no deficiencies or citations were substantiated.

No regulatory citations or deficiencies were identified as a result of the inspection.

The inspection was complaint and incident related; no deficiencies or citations were found, indicating no substantiated issues.

No regulatory citations or deficiencies were identified during the inspection.

The inspection was complaint-related and interim in nature, with a follow-up plan of correction submission due by 08/25/2024. The complaint involved medication administration errors and safety concerns in the secured dementia care unit.

The facility was found to have multiple deficiencies including medication errors, failure to report incidents timely, locked egress gate in the secured dementia care unit, missing exit signs, and incomplete evacuation diagrams. Plans of correction were accepted and implemented by 08/21/2024.

The abuse allegation against staff persons A and B was substantiated by the AAA investigation. Staff persons A and B were suspended and subsequently terminated due to abuse of resident #1.

The investigation substantiated abuse allegations against staff persons A and B involving mistreatment of resident #1. Additionally, a deficiency was found in the preadmission screening form documentation for resident #1. The submitted plan of correction was accepted and fully implemented.

The inspection was complaint-related with a follow-up plan of correction submission. The violation was a repeat from 2/7/2024 and was addressed with education and audits to ensure compliance.

The submitted plan of correction was found to be fully implemented. A repeat violation was noted regarding incomplete documentation in the resident's support plan, specifically related to diet orders and incontinence care.

No regulatory citations or deficiencies were identified during this inspection.

The facility was found to be in compliance after corrections were made following the inspection. Several deficiencies were identified related to staff training, safety hazards, medication storage, and adherence to prescriber orders, all of which were corrected with plans of correction implemented.

The facility was found to have implemented the plan of correction fully with multiple deficiencies addressed, including fire safety training, exit sign repairs, lighting issues, unobstructed egress, medication storage, medication administration errors, and support plan updates. Ongoing monitoring and training plans were established for continued compliance.

No regulatory citations or deficiencies were identified as a result of this inspection.

The Department reviewed the submitted information and determined that the informed consent process includes voluntary participation, the right to discontinue use of cameras, and notification of residents' rights, satisfying regulatory requirements around privacy.

The facility was found to have multiple deficiencies including unsigned resident contracts, unverified staff qualifications, unsafe resident equipment, improper water temperature, combustible storage hazards, incomplete fire drill records, incomplete medical evaluations, medication storage and labeling issues, and incomplete resident support plans. All deficiencies had plans of correction accepted and were implemented by 11/13/2023.

The facility was found to have fully implemented the submitted plan of correction addressing multiple repeat violations including medication administration errors, failure to report incidents timely, treatment of residents with dignity, medication record keeping, following prescriber's orders, medication error reporting, and updating resident support plans. Continued compliance must be maintained.

The complaint investigation was triggered by a medication error on 6/5/23 where Resident #1 was given Resident #2's medications, resulting in Resident #1's death. The facility failed to report the incident timely and did not follow proper medication administration protocols. The medication error was not immediately reported to the resident, family, or prescriber. The investigation substantiated gross negligence and incompetence.

The inspection found multiple violations including a medication error resulting in a resident's death, failure to timely report incidents, improper medication administration, failure to follow prescriber's orders, inadequate medical evaluations, and insufficient documentation in resident support plans. The facility was issued a provisional license with required corrective actions and training.

The visit was complaint-related as indicated by the inspection information section. The plan of correction was reviewed and determined to be fully implemented.

The facility was found to have multiple deficiencies related to medication administration, assistance with activities of daily living, incident reporting, refusal of medication, and follow prescriber's orders. The submitted plan of correction was accepted and fully implemented as of the follow-up review.

The inspection was triggered by a complaint and incident, as noted in the inspection information section.

Multiple deficiencies were found related to staffing hours during waking hours, medication self-administration assessments, medication labeling and storage, unauthorized medications, mobility assessments, and support plan documentation and signatures. The facility submitted a plan of correction which was accepted and implemented by January 25, 2023.

The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.

No regulatory citations or deficiencies were identified as a result of this inspection.

The facility was found to have multiple deficiencies including failure to timely report resident abuse and medication errors, confidentiality breaches, incomplete resident contracts, safety hazards with resident equipment, missing emergency phone signage, inadequate lighting in resident rooms, incomplete medical evaluations, medication storage and administration issues, incomplete support plans, and missing resident record content. All deficiencies had plans of correction accepted and were implemented by early 2023.

The visit was complaint-related as indicated by the reason for inspection and the unannounced nature of the visit.

The inspection identified multiple deficiencies including unlocked medication carts and resident records, insufficient direct care staffing hours, lack of monthly fire drills, incomplete fire drill records, inadequate program activities, and outdated resident assessments and support plans. Plans of correction were accepted and staff training and monitoring were implemented.

No inspection findings are reported in this document; it is a license renewal letter and certificate of compliance confirming the facility's authorized operation and capacity.

The inspection identified several deficiencies related to health and safety laws, physical accommodations, exit signage, and first aid kit contents. All deficiencies were corrected on the day of inspection with plans of correction accepted and implemented.

No regulatory citations were identified as a result of this inspection.

No regulatory citations were identified as a result of this inspection.

The plan of correction was determined to be fully implemented, with continued compliance required. The specific deficiency involved the improper use of a glucometer between residents.

The Department issued a regular license in response to the renewal application and advised that an onsite inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.

The plan of correction related to a sanitary conditions violation involving the improper use of a glucometer was found to be fully implemented. Continued compliance is required.

The inspection was triggered by a complaint or incident, as indicated by the partial inspection type and reason 'Complaint/Incident'.

The report identified multiple deficiencies related to resident care including failure to provide assistance with activities of daily living, incomplete medication administration training, inadequate pre-admission screening, delayed resident assessments, and incomplete updates to resident support plans. Plans of correction were submitted and approved with implementation status confirmed on March 25, 2020.

Multiple violations of state regulations were identified, including issues with residents' rights, staff training, food labeling, fire safety, medical evaluations, medication management, smoking policies, and resident assessment plans. Corrective actions and training plans were implemented with completion dates mostly by August 31, 2019.

The inspection was complaint-driven. Specific substantiation status is not stated.

The inspection found violations related to medical evaluations, specifically a resident's medical exam was not obtained within the required timeframe. A plan of correction was submitted to address the deficiencies.

No inspection findings are reported in this document; it is an administrative notice confirming license renewal and future inspection requirements.

The complaint involved an allegation of sexual abuse of Resident #1 that was not reported timely. An internal investigation found no substantiated statements supporting the allegation. The resident's allegation could not be substantiated.

The inspection found citations related to failure to report suspected sexual abuse, incomplete medical evaluations, and missing resident signatures on support plans. Plans of correction were partially implemented with ongoing monitoring and staff training scheduled.

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 new legal entity status.