Inspection Reports for Celebration Villa of Berwick
2050 WEST FRONT STREET,, BERWICK, PA, 18603
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
9.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
96% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
54% occupied
Based on a September 2025 inspection.
Census over time
Inspection Report
Renewal
Census: 41
Capacity: 76
Deficiencies: 4
Sep 4, 2025
Visit Reason
The inspection was conducted as a renewal inspection of the facility license.
Findings
The inspection found several deficiencies including a medication cart left unattended with accessible records, an unlabeled bar of soap in a shared bathroom, missing items in the van first aid kit, and a medication not available for a resident. The submitted plan of correction was determined to be fully implemented.
Deficiencies (4)
| Description |
|---|
| Medication cart was unattended with laptop screen open and medication administration records accessible. |
| Unlabeled used bar of soap found in shared bathroom located in room 131. |
| First aid kit in the van used to transport residents did not include tweezers and protective eye coverings. |
| Resident 1's prescribed medication Acetaminophen 325MG 650 was not available in the home at the time of inspection. |
Report Facts
License Capacity: 76
Residents Served: 41
Total Daily Staff: 45
Waking Staff: 34
Residents 60 Years or Older: 4
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 4
Residents with Physical Disability: 2
Inspection Report
Follow-Up
Census: 46
Capacity: 76
Deficiencies: 1
Apr 10, 2025
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 04/10/2025 to review compliance and verify the submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented as of 04/10/2025. The main deficiency involved the resident support plan lacking documentation of a two-person assist for transferring, which was corrected and updated by the Executive Director.
Complaint Details
The inspection was complaint-related and the plan of correction was accepted and fully implemented. No substantiation status explicitly stated.
Deficiencies (1)
| Description |
|---|
| Resident support plan did not contain information about requiring a 2 person assist for transferring. |
Report Facts
License Capacity: 76
Residents Served: 46
Current Hospice Residents: 2
Total Daily Staff: 53
Waking Staff: 40
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 7
Residents with Physical Disability: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Named in plan of correction for updating resident support plan and educating clinical leadership team | |
| Director of Nursing | Involved in ongoing review and update of resident assessment and support plans | |
| Assistant Director of Nursing | Involved in ongoing review and update of resident assessment and support plans |
Inspection Report
Census: 43
Capacity: 76
Deficiencies: 0
Mar 5, 2025
Visit Reason
The inspection was a partial, unannounced licensing inspection conducted due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Resident Support Staff: 7
Total Daily Staff: 57
Waking Staff: 43
Residents Served: 43
License Capacity: 76
Residents with Mobility Need: 7
Residents Age 60 or Older: 43
Inspection Report
Census: 43
Capacity: 76
Deficiencies: 0
Dec 27, 2024
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, with the reason noted as 'Incident' and the inspection type as 'Partial' and unannounced.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 50
Waking Staff: 38
Resident Support Staff: 0
Residents Served: 43
License Capacity: 76
Current Hospice Residents: 0
Residents Age 60 or Older: 43
Residents with Mobility Need: 7
Residents with Physical Disability: 1
Residents Diagnosed with Mental Illness: 0
Residents Diagnosed with Intellectual Disability: 0
Residents Receiving Supplemental Security Income: 0
Inspection Report
Complaint Investigation
Census: 45
Capacity: 76
Deficiencies: 1
Mar 12, 2024
Visit Reason
The inspection was conducted as a complaint investigation with an interim exit conference on 03/12/2024 to review compliance and the submitted plan of correction.
Findings
The investigation found that staff were leaving medications in cups for residents to take without ensuring the residents actually took the medications. The submitted plan of correction was accepted and fully implemented by 04/01/2024.
Complaint Details
The visit was complaint-related and interim in nature. The complaint was substantiated by staff and resident interviews confirming medication administration issues.
Deficiencies (1)
| Description |
|---|
| Staff left medications in cups for residents to take and left resident rooms without ensuring that the residents took the medications. |
Report Facts
License Capacity: 76
Residents Served: 45
Current Hospice Residents: 4
Residents 60 Years or Older: 45
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 7
Residents with Physical Disability: 2
Total Daily Staff: 52
Waking Staff: 39
Inspection Report
Follow-Up
Census: 46
Capacity: 76
Deficiencies: 4
Feb 1, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident involving medication diversion and tampering.
Findings
The facility was found to have multiple deficiencies related to medication diversion by a staff member who tampered with narcotic blister packs, replacing Oxycodone with other medications. The staff member was identified, suspended, and terminated following a police investigation. The facility implemented corrective actions including staff education, medication audits, and improved storage procedures.
Deficiencies (4)
| Description |
|---|
| Resident funds and property were used improperly due to medication diversion by a staff member tampering with narcotic blister packs. |
| Failure to implement safe storage, access, security, distribution, and use of medications by trained staff persons. |
| Failure to follow prescriber's orders resulting in residents not receiving prescribed Oxycodone due to diversion. |
| Records of active and discharged residents were not maintained confidentially, as a discarded blister pack with resident information was found accessible. |
Report Facts
License Capacity: 76
Residents Served: 46
Current Hospice Residents: 4
Residents 60 Years or Older: 45
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 7
Residents with Physical Disability: 2
Total Daily Staff: 53
Waking Staff: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member C | Medication Technician | Identified as the offending staff member who diverted medications and admitted to drug diversion. |
| Executive Director | Led investigation, reported incident to Department of Human Services, and implemented corrective actions including staff education and audits. |
Inspection Report
Complaint Investigation
Census: 47
Capacity: 76
Deficiencies: 0
Dec 14, 2023
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Complaint Details
The inspection was incident-related, indicating a complaint or concern triggered the visit.
Report Facts
Total Daily Staff: 54
Waking Staff: 41
Residents Served: 47
License Capacity: 76
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 7
Residents Age 60 or Older: 47
Inspection Report
Complaint Investigation
Census: 50
Capacity: 76
Deficiencies: 2
Oct 23, 2023
Visit Reason
The inspection was conducted as a complaint investigation to review the facility's compliance with regulations, specifically regarding the use of AI technology in toilets without proper waivers or consent.
Findings
The facility was found to have used TrueLoo AI technology toilets without obtaining the required waiver or explicit written consent from residents, violating privacy and waiver regulations. The facility submitted and implemented a plan of correction to discontinue the use of the AI toilets and provide staff education.
Complaint Details
The visit was complaint-related, triggered by concerns about the use of AI technology toilets without proper waivers or consent. The plan of correction was accepted and fully implemented.
Deficiencies (2)
| Description |
|---|
| Use of TrueLoo AI technology toilets without obtaining a waiver as required by regulation 2600.19. |
| Violation of residents' privacy by using AI technology toilets without explicit written consent and without Department approval, violating regulation 2600.42s. |
Report Facts
License Capacity: 76
Residents Served: 50
Total Daily Staff: 59
Waking Staff: 44
Plan of Correction Completion Date: Dec 15, 2023
Inspection Report
Renewal
Census: 48
Capacity: 76
Deficiencies: 11
Sep 12, 2023
Visit Reason
The inspection was an unannounced full renewal inspection conducted to review compliance with licensing regulations.
Findings
The facility was found to have multiple deficiencies including failure to post the current license inspection summary, lack of carbon monoxide detectors near gas water heaters, incomplete annual staff training, inadequate lighting in resident rooms, outdated food items, obstructed egress routes, combustible storage near heat sources, incomplete fire drill records, medication errors including administration of non-current prescriptions, and incomplete resident support plan signatures. Plans of correction were accepted and implemented with ongoing monitoring.
Deficiencies (11)
| Description |
|---|
| The home did not have the License Inspection Summary (LIS) report dated 6/1/22 posted conspicuously in the home as required. |
| The home’s gas fired hot water heater did not have a carbon monoxide monitor installed 15 feet from it as required by the Care Facility Carbon Monoxide Monitoring Act. |
| Staff persons A and B did not have annual training on emergency preparedness and resident rights for the 2022 training year. Staff person C did not have fire safety training by a fire safety expert or training on emergency preparedness for the 2022 training year. |
| Room 149 did not have a light source that could be reached at bedside. |
| In the kitchen there was freeze dried dill with a date of 5/4 on it, there was no year. There were 3 containers of sour cream in the refrigerator all expired. There was a container of Hershey’s Strawberry Syrup with an expiration date of 8/2023. |
| Exit #4 was blocked from egress due to a resident sitting outdoors directly in front of the exit. A row of chairs in the activity room were placed directly in the path of the exit door. |
| Combustible and flammable materials were located near heat sources or hot water heaters including cardboard, paint cans, and cigarette butts in the smoking area. |
| Fire drill records were incomplete, recorded only in minutes not minutes and seconds, and not all residents were evacuated during certain fire drills. |
| Medication cart contained a blister pack of tablets for resident #1 without a current order. Medication errors included administering medications not currently ordered and failure to follow prescriber's orders. |
| Staff person A administering insulin did not have training by a certified diabetes educator within the last 12 months. |
| Resident Assessment and Support Plan for Resident #5 was not signed by the resident with no indication why. |
Report Facts
License Capacity: 76
Residents Served: 48
Total Daily Staff: 61
Waking Staff: 46
Outdated Food Items: 3
Fire Drills Recorded in Minutes Only: 9
Residents Not Evacuated in Fire Drills: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Med Tech | Named in insulin administration training deficiency and medication administration errors |
| Director of Nursing | Named in medication cart audits and medication error corrections | |
| Executive Director | Named in multiple findings including training, monitoring, and corrective actions | |
| Maintenance Director | Named in corrective actions related to carbon monoxide detectors, combustible storage, and fire safety | |
| Dining Services Director | Named in corrective actions related to outdated food |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 76
Deficiencies: 3
Jul 26, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation to review compliance and the submitted plan of correction.
Findings
The inspection found deficiencies related to resident #1's assistance with activities of daily living, sanitary conditions due to frequent incontinence, and incomplete support plan documentation. The submitted plan of correction was determined to be fully implemented.
Complaint Details
The visit was complaint-related and involved an incident. The submitted plan of correction was fully implemented as of the inspection date.
Deficiencies (3)
| Description |
|---|
| Resident #1 was not provided a replacement call bell pendant for at least one week and was not scheduled for regular toileting checks or dressed with a brief instead of underwear. |
| Resident #1's room had a strong odor of urine and feces due to frequent urinary and bowel incontinence. |
| Resident #1's support plan was not updated to reflect frequent urinary and bowel accidents and refusal of scheduled shower assistance. |
Report Facts
License Capacity: 76
Residents Served: 46
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 10
Residents Age 60 or Older: 46
Resident Support Staff: 0
Total Daily Staff: 56
Waking Staff: 42
Inspection Report
Follow-Up
Census: 47
Capacity: 76
Deficiencies: 4
Apr 6, 2023
Visit Reason
The inspection visit on 04/06/2023 was a partial, unannounced incident-related review to verify the implementation of a previously submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented. The report details deficiencies related to abuse, support plan revisions, medical/dental support plan documentation, and support plan signatures, all of which have corrective actions and training planned or completed.
Deficiencies (4)
| Description |
|---|
| Resident #1 pushed Resident #2 causing injury requiring hospital treatment; abuse prevention and wandering behavior management training planned. |
| Support plan for Resident #2 was not revised timely to reflect significant changes in care needs. |
| Resident #2's support plan medical/dental assessment was inaccurate regarding mobility and assistance needs. |
| Resident #1's and Resident #2's support plans were not signed by the resident or assessor. |
Report Facts
License Capacity: 76
Residents Served: 47
Hospice Current Residents: 4
Residents Age 60 or Older: 47
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 10
Total Daily Staff: 57
Waking Staff: 43
Inspection Report
Complaint Investigation
Census: 46
Capacity: 76
Deficiencies: 0
Mar 15, 2023
Visit Reason
The inspection was conducted as a complaint-related investigation due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The visit was complaint-related with the reason stated as 'Incident'. No deficiencies or citations were found.
Report Facts
Total Daily Staff: 56
Waking Staff: 42
Residents Served: 46
License Capacity: 76
Residents Diagnosed with Mental Illness: 2
Residents with Mobility Need: 10
Residents 60 Years of Age or Older: 46
Inspection Report
Complaint Investigation
Census: 47
Capacity: 76
Deficiencies: 1
Oct 19, 2022
Visit Reason
The inspection was conducted as a complaint and incident investigation at Celebration Villa of Berwick on 10/19/2022.
Findings
The facility was found to have a deficiency related to the failure to update Resident #1's support plan regarding behaviors towards other residents and how the home would meet the resident's needs. The submitted plan of correction was fully implemented as of 02/22/2023.
Complaint Details
The inspection was complaint-related and incident-based. The plan of correction was accepted on 12/07/2022 and fully implemented by 02/22/2023.
Deficiencies (1)
| Description |
|---|
| Resident #1's RASP had not been updated regarding the resident's behaviors towards other female residents or how the home is going to meet the resident's needs. |
Report Facts
License Capacity: 76
Residents Served: 47
Current Hospice Residents: 1
Resident Support Staff: 6
Total Daily Staff: 59
Waking Staff: 44
Residents Age 60 or Older: 47
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 6
Inspection Report
Monitoring
Census: 47
Capacity: 76
Deficiencies: 0
Aug 9, 2022
Visit Reason
The inspection was a monitoring visit conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, to assess compliance at the facility.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
License Capacity: 76
Residents Served: 47
Current Hospice Residents: 0
Residents Age 60 or Older: 47
Residents with Mobility Need: 15
Residents with Physical Disability: 1
Inspection Report
Renewal
Census: 47
Capacity: 76
Deficiencies: 8
Jun 1, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.
Findings
The inspection found multiple deficiencies related to resident confidentiality, emergency preparedness, medical evaluations, medication administration, and record content. All deficiencies had plans of correction submitted and were verified as implemented on-site.
Deficiencies (8)
| Description |
|---|
| Resident #1’s dialysis schedule was posted on the medication cart accessible to unauthorized persons. |
| The home’s exterior garbage dumpster was found open with the lid up, allowing potential infestation. |
| Resident room #133 did not have required emergency telephone numbers posted near the phone. |
| Resident room #135 had 3 throw rugs in the bathroom creating a slip-fall risk. |
| Fire drill evacuation time exceeded the allowed time; fire drills did not alternate evacuation routes; residents did not fully evacuate during overnight fire drills. |
| Resident #2 did not have annual medical evaluations completed for years 2020, 2021, and 2022. |
| Resident #3 had medications left unattended at bedside during inspection. |
| Resident records for residents #4, #5, #6, and #7 did not indicate if they had identifiable marks. |
Report Facts
License Capacity: 76
Residents Served: 47
Staffing Hours: 53
Waking Staff: 40
Residents with Mobility Need: 6
Residents 60 Years or Older: 47
Residents Diagnosed with Mental Illness: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| NJAMIN | Administrator | Named in relation to education and monitoring for multiple deficiencies including confidentiality, emergency preparedness, and record content. |
| Unnamed Med-Tech | Med-Tech | Counseled for failure to administer medication and leaving medication unattended. |
| Maintenance Director | Educated on fire drill evacuation times, alternating evacuation routes, and full evacuation during overnight fire drills. | |
| Director of Nursing | Educated med-techs on medication administration regulations and was educated on annual medical evaluation compliance. |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 76
Deficiencies: 4
Feb 2, 2022
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulations at Celebration Villa of Berwick.
Findings
The inspection found violations related to insufficient showers for residents, failure to test smoke detectors monthly, failure to conduct unannounced fire drills in December 2021 and January 2022, and lack of a supervised fire drill by a fire safety expert since March 2020. Plans of correction were submitted and accepted with completion dates in early 2022, and evidence of compliance was documented by November 4, 2022.
Complaint Details
The inspection was triggered by a complaint as noted in the Inspection Information section on page 2.
Deficiencies (4)
| Description |
|---|
| The home currently has one working shower for 27 residents, with 19 residents having their own personal shower. |
| The home has not tested the fire alarms monthly from 4/20/21 to 1/22. |
| The home did not conduct a fire drill in December 2021 and January 2022. |
| The home has not had a supervised fire drill conducted by a fire safety expert since 3/12/20. |
Report Facts
License Capacity: 76
Residents Served: 46
Current Residents in Hospice: 4
Residents with Mental Illness: 1
Residents with Mobility Need: 7
Residents Age 60 or Older: 49
Total Daily Staff: 53
Waking Staff: 40
Inspection Report
Renewal
Capacity: 76
Deficiencies: 0
Jul 9, 2021
Visit Reason
The document is a renewal license issued in response to the May 13, 2021 renewal application to operate the Personal Care Home Elmcroft of Berwick. The Department advises that an onsite inspection will be conducted within the next twelve months as required by regulation.
Findings
The license renewal was granted and a regular license issued. The Department will conduct an inspection within the next twelve months and take enforcement action if noncompliance is found.
Report Facts
Maximum capacity: 76
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed letter regarding license renewal and inspection requirements |
Inspection Report
Renewal
Census: 46
Capacity: 76
Deficiencies: 3
May 11, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license.
Findings
The facility was found to have deficiencies related to emergency exterior lighting, incomplete annual medical evaluations, and improper medication storage. Plans of correction were accepted and implemented, with follow-up reviews confirming compliance.
Deficiencies (3)
| Description |
|---|
| Emergency exterior lighting is not provided on the rear wooden fire escape closest to the shed, posing a safety risk during emergency evacuation. |
| An annual medical evaluation for resident #1 did not include required information such as date evaluated, date form completed, height, weight, pulse rate, or temperature. |
| An Anoro inhaler belonging to resident #1 was not dated as to when it was first used, contrary to manufacturer requirements. |
Report Facts
License Capacity: 76
Residents Served: 46
Total Daily Staff: 54
Waking Staff: 41
Deficiencies cited: 3
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