Deficiencies per Year
12
9
6
3
0
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Plan of Correction
Census: 53
Capacity: 65
Deficiencies: 2
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.
Deficiencies (2)
| Description |
|---|
| 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
License Capacity: 65
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 |
Inspection Report
Complaint Investigation
Census: 42
Capacity: 65
Deficiencies: 1
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.
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.
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.
Deficiencies (1)
| Description |
|---|
| 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
License Capacity: 65
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
Renewal
Census: 51
Capacity: 65
Deficiencies: 12
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.
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.
Complaint Details
The inspection included a complaint investigation component as indicated by the reason for visit and follow-up on plan of correction submissions.
Deficiencies (12)
| Description |
|---|
| 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
License Capacity: 65
Residents Served: 51
Current Hospice Residents: 3
Total Daily Staff: 53
Waking Staff: 40
Deficiency Completion Dates: 9
Inspection Report
Renewal
Deficiencies: 0
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
Capacity: 65
Deficiencies: 0
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
Total licensed capacity: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter. |
Inspection Report
Renewal
Census: 32
Capacity: 65
Deficiencies: 6
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.
Deficiencies (6)
| Description |
|---|
| 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
License Capacity: 65
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
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