Inspection Reports for Celebration Villa of Lewisburg
2421 Old Turnpike Rd Lewisburg, PA, 17837, PA, 17837
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
24.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
415% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
52% occupied
Based on a August 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Census: 38
Capacity: 73
Deficiencies: 7
Aug 7, 2025
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by a complaint and incident review to verify the implementation of a previously submitted plan of correction.
Findings
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.
Complaint Details
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.
Deficiencies (7)
| Description |
|---|
| Failure to immediately report suspected resident abuse to the Area Agency on Aging. |
| Failure to report an incident and power outage to the Department’s personal care home regional office within 24 hours. |
| Staff verbally abused a resident by repeatedly addressing them with derogatory slurs. |
| Fire exit doors were blocked by a chair and a large trash can. |
| Trash can at facility entrance contained cigarette butts and flammable materials, violating smoking area guidelines. |
| An unattended medication treatment cart was found unlocked and accessible in the hallway. |
| Resident record lacked documentation that the resident and designated person did not object to admission to the secured dementia care unit. |
Report Facts
License Capacity: 73
Residents Served: 38
Secured Dementia Care Unit Capacity: 17
Secured Dementia Care Unit Residents Served: 10
Current Hospice Residents: 4
Residents with Mobility Need: 11
Residents Age 60 or Older: 38
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Named in findings related to verbal abuse of a resident and subsequent suspension and termination. | |
| Executive Director | Responsible for reporting incidents, training staff, and implementing corrective actions. | |
| Director of Nursing | Involved in staff training and monitoring compliance with regulations. |
Inspection Report
Renewal
Census: 36
Capacity: 73
Deficiencies: 16
Mar 19, 2025
Visit Reason
The inspection was conducted as part of a renewal, complaint, and incident investigation at Celebration Villa of Lewisburg on March 19 and March 26, 2025.
Findings
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.
Complaint Details
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.
Deficiencies (16)
| Description |
|---|
| Batteries in carbon monoxide detectors were not replaced annually or dated. |
| Resident #2 did not receive scheduled showering and assistance due to staff shortages, resulting in falls and injuries. |
| Resident #3 was found in soiled incontinence briefs for extended periods, indicating neglect. |
| Resident #2's privacy was violated when a staff member showed a photo of bruising to a family member. |
| Insufficient staffing on overnight shifts to meet residents' needs and emergencies. |
| Direct care staff persons lacked required training and supervised practice before providing unsupervised ADL services. |
| Direct care staff did not complete required 12 hours of annual training or required training topics. |
| Resident #2's bed cane was not properly secured, posing injury risk. |
| Unlabeled and undated leftover food found in freezer. |
| Accumulation of lint in dryer lint traps in laundry areas. |
| Combustible materials stored near heat sources in laundry rooms. |
| Fire drill evacuation time exceeded the safe evacuation time specified by fire safety expert. |
| Unlocked and unattended medication cart found. |
| Support plan for Resident #1 in secured dementia care unit was not completed within 72 hours of admission. |
| Direct care staff person did not complete required 6 hours of annual dementia care training. |
| Correction fluid used in resident #2's medical evaluation record entries. |
Report Facts
License Capacity: 73
Residents Served: 36
Secured Dementia Care Unit Capacity: 17
Residents Served in SDCU: 13
Current Hospice Residents: 3
Residents with Mobility Needs: 20
Residents Requiring 2-Person Assist: 7
Staff on Overnight Shift: 3
Call Bell Wait Times: 679
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed the provisional license letter. |
| Staff person D | Named in findings related to incomplete training and dementia care training. | |
| Staff person F | Named in privacy violation for showing photo of resident's bruising. | |
| Staff person E | Confirmed staffing shortages affecting resident care. | |
| Maintenance Director | Performed corrective actions related to carbon monoxide detectors, bed cane, lint removal, combustible storage, and fire drill. | |
| Executive Director | Educated on multiple regulations and responsible for oversight and corrective actions. | |
| Regional Director of Operations | Provided education and training on regulations to staff. | |
| Regional Director of Clinical Services | Conducted audits related to resident assessments and support plans. | |
| Dietary Director | Conducted audits and education related to food safety. |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 73
Deficiencies: 4
Feb 13, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation to review concerns regarding resident care and compliance with regulations.
Findings
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.
Complaint Details
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.
Deficiencies (4)
| Description |
|---|
| Failure to provide adequate personal hygiene care and feeding assistance to a resident, including overnight bladder management checks. |
| Medications were found in a resident's room on multiple occasions instead of being administered properly. |
| Resident assessment and support plan was not updated timely to reflect changes in resident's condition. |
| Support plan was not signed by the staff person who completed the form. |
Report Facts
Residents Served: 40
License Capacity: 73
Secured Dementia Care Unit Capacity: 17
Secured Dementia Care Unit Residents Served: 11
Hospice Current Residents: 5
Residents Age 60 or Older: 40
Residents with Mobility Need: 14
Total Daily Staff: 54
Waking Staff: 41
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in relation to education and audits for medication administration and resident care deficiencies |
| Memory Care Coordinator | Memory Care Coordinator | Named in relation to education and audits for medication administration and resident care deficiencies |
| Executive Director | Executive Director | Named in relation to oversight and auditing of resident assessment and support plans |
| Regional Director of Operations | Regional Director of Operations | Provided education on regulations to staff |
| Regional Director of Clinical Services | Regional Director of Clinical Services | Provided education on regulations to staff |
Inspection Report
Follow-Up
Census: 49
Capacity: 73
Deficiencies: 1
Nov 26, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident at the facility.
Findings
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.
Deficiencies (1)
| Description |
|---|
| Resident was heard screaming; staff member B was alleged to have grabbed the resident's neck and caused fear. Investigation found no substantiated abuse but required corrective actions. |
Report Facts
License Capacity: 73
Residents Served: 49
Secured Dementia Care Unit Capacity: 17
Secured Dementia Care Unit Residents Served: 12
Hospice Current Residents: 4
Residents Age 60 or Older: 49
Residents with Mobility Need: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Person A | Named in abuse allegation and subsequent suspension, retraining, and supervision plan | |
| Executive Director | Responded to incident, interviewed staff, reported to authorities, and submitted plan of correction | |
| Director of Nursing | Responded to incident, conducted resident assessment, reported to authorities, and involved in training and corrective actions | |
| Memory Care Coordinator | Investigated incident and involved in ongoing staff training and supervision | |
| Regional Director of Operations | Submitted plan of supervision and training for Staff Person A |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 73
Deficiencies: 0
Aug 28, 2024
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on 08/14/2024 and 08/28/2024.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were substantiated.
Report Facts
Residents Served: 35
License Capacity: 73
Current Hospice Residents: 3
Total Daily Staff: 35
Waking Staff: 26
Residents Age 60 or Older: 35
Inspection Report
Complaint Investigation
Census: 35
Capacity: 73
Deficiencies: 0
Aug 14, 2024
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial visits on 08/14/2024 and 08/28/2024.
Findings
No regulatory citations or deficiencies were identified as a result of the inspection.
Complaint Details
The visit was complaint-related, but no deficiencies or citations were substantiated.
Report Facts
Residents Served: 35
License Capacity: 73
Current Hospice Residents: 3
Total Daily Staff: 35
Waking Staff: 26
Inspection Report
Complaint Investigation
Census: 38
Capacity: 73
Deficiencies: 0
Aug 8, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation at the facility.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Complaint Details
The inspection was complaint and incident related; no deficiencies or citations were found, indicating no substantiated issues.
Report Facts
Resident Support Staff: 40
Waking Staff: 30
Residents Served: 38
License Capacity: 73
Current Residents: 2
Residents Age 60 or Older: 38
Residents with Mobility Need: 2
Inspection Report
Complaint Investigation
Census: 38
Capacity: 73
Deficiencies: 7
Jul 30, 2024
Visit Reason
The inspection was conducted as a complaint investigation with an interim exit conference on 07/30/2024 to review compliance and plan of correction implementation.
Findings
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.
Complaint Details
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.
Deficiencies (7)
| Description |
|---|
| Resident #1 and Resident #2 did not receive prescribed medications and the home failed to submit incident reports regarding these medication errors. |
| The gate to the secured dementia care unit courtyard was locked, obstructing egress. |
| The emergency evacuation diagram did not include the newly created exit to the secured dementia care unit courtyard. |
| No exit sign was posted at the exit leading to the enclosed courtyard in the proposed memory care unit. |
| Resident #1 refused prescribed medications but the refusal was not documented or reported to the prescriber within 24 hours. |
| Medication administration errors related to following prescriber's orders and parameters for Resident #1 were identified. |
| Medication errors were not immediately reported to the resident, designated person, and prescriber as required. |
Report Facts
License Capacity: 73
Residents Served: 38
SDCU Capacity: 17
SDCU Residents Served: 0
Total Daily Staff: 39
Waking Staff: 29
Current Hospice Residents: 2
Residents with Mobility Need: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed the license approval letter. |
| Director of Nursing | Named in multiple medication error findings and responsible for submitting incident reports and training staff. | |
| Regional Director of Clinical Services | Trained Director of Nursing and Care Coordinator on medication regulations. | |
| Care Coordinator | Involved in training and ongoing medication error monitoring. | |
| Maintenance Director | Responsible for unlocking the secured dementia care unit gate and trained on related regulations. | |
| Executive Director | Provided training on exit signs and evacuation diagrams, and monitored ongoing compliance. | |
| Regional Director of Operations | Updated evacuation diagrams to include new exits. |
Inspection Report
Plan of Correction
Census: 36
Capacity: 73
Deficiencies: 2
Jul 9, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation, followed by review of the submitted plan of correction to verify compliance.
Findings
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.
Complaint Details
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.
Deficiencies (2)
| Description |
|---|
| Resident #1 was verbally abused and mistreated by staff person A, including leaving the overhead light on as punishment and cursing at the resident. |
| The preadmission screening form for resident #1 was not dated and did not indicate if the resident could safely use and avoid poisonous materials. |
Report Facts
Residents Served: 36
License Capacity: 73
Current Residents in Hospice: 3
Residents Age 60 or Older: 36
Residents with Mobility Need: 4
Inspection Report
Complaint Investigation
Census: 36
Capacity: 73
Deficiencies: 1
Jun 13, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation at Celebration Villa of Lewisburg on 06/13/2024.
Findings
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.
Complaint Details
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.
Deficiencies (1)
| Description |
|---|
| Resident's support plan did not document changes to a mechanical soft diet and lacked information on incontinence care and physical assistance. |
Report Facts
License Capacity: 73
Residents Served: 36
Total Daily Staff: 40
Waking Staff: 30
Repeat Violation Date: Feb 7, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in relation to updating the Resident Assessment and Support Plan and involved in training and corrective actions. |
| Regional Director of Clinical Services | Regional Director of Clinical Services | Provided education to the Director of Nursing on the Resident Assessment and Support Plan audit tool. |
| Executive Director | Executive Director | Responsible for educating staff and overseeing audits and quality assurance meetings. |
Inspection Report
Census: 35
Capacity: 73
Deficiencies: 0
Apr 2, 2024
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.
Report Facts
Residents Served: 35
License Capacity: 73
Current Hospice Residents: 3
Total Daily Staff: 35
Waking Staff: 26
Inspection Report
Follow-Up
Census: 38
Capacity: 73
Deficiencies: 8
Feb 7, 2024
Visit Reason
The inspection visit on 02/07/2024 was a full, unannounced follow-up to verify the implementation of a previously submitted plan of correction for the facility.
Findings
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.
Deficiencies (8)
| Description |
|---|
| Staff persons A, B, and C did not receive fire safety training completed by a fire safety expert during training year 2023. |
| The illuminated exit sign in front of exit door C was hanging only by electrical wires and not connected to the ceiling anchor. |
| The bedside lamp for Resident #1 was without a light bulb, leaving no operable light available bedside. |
| Two of the four exit doors in the activity room were obstructed by chairs and tables preventing immediate egress. |
| Three exits leading from the activity room to the outside did not have exit signs posted near them. |
| During medication cart audit, a loose pill was discovered in cart 2, drawer 2, which could not be identified and was properly disposed of. |
| Resident #2 was administered a second dose of medication at an incorrect time, not following the prescriber's orders. This was a repeat violation. |
| The most recent Resident Assessment Support Plan (RASP) for Resident #4 was not updated to reflect a physician order allowing self-administration of two medications bedside. This was a repeat violation. |
Report Facts
Residents Served: 38
License Capacity: 73
Total Daily Staff: 39
Waking Staff: 29
Current Hospice Residents: 1
Residents Age 60 or Older: 38
Residents with Mobility Need: 1
Residents with Physical Disability: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in multiple findings related to fire safety training, exit sign repair, lamp maintenance, obstruction removal, and medication storage | |
| Executive Director | Trained Maintenance Director and staff on various regulations and oversaw corrective actions | |
| Director of Nursing | Involved in medication error reporting, staff training, and updating resident support plans | |
| Medication Technician | Involved in medication administration error and medication cart audit |
Inspection Report
Census: 53
Capacity: 73
Deficiencies: 0
Jan 16, 2024
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 59
Waking Staff: 44
Resident Support Staff: 0
Residents Served: 53
License Capacity: 73
Current Hospice Residents: 2
Residents 60 Years or Older: 53
Residents with Mobility Need: 6
Inspection Report
Monitoring
Census: 42
Capacity: 73
Deficiencies: 14
Oct 17, 2023
Visit Reason
The inspection was an unannounced full monitoring visit conducted as an interim review to verify compliance and follow-up on previous deficiencies.
Findings
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.
Deficiencies (14)
| Description |
|---|
| Resident home contracts for two residents were not signed by the residents. |
| Staff member lacked verification of a High School Diploma, GED, or active Nursing Aide Assistant registry. |
| Halo safety ring attached to resident's bed was not securely attached, causing a safety hazard. |
| Hot water temperature of 122.5 degrees measured in bathroom of room 113. |
| Combustible materials (dryer sheet and sock) found behind dryer posing fire hazard. |
| Fire drill record incomplete; missing evacuation time, exit routes, resident counts, alarm status, and corrective actions. |
| Medical evaluation documentation missing resident height and weight; another missing evaluation date. |
| Annual medical evaluation for a resident was completed late. |
| Medication cart was found unlocked and unattended. |
| Expired Novolog pen found in medication cart. |
| OTC medication bottle not labeled with resident's name. |
| Glucometer calibrated to incorrect date and time. |
| Resident support plan did not document specific need, risks, or safe use of Halo safety ring. |
| Resident support plan was not signed by resident without notation of refusal or inability. |
Report Facts
License Capacity: 73
Residents Served: 42
Staffing Hours: 43
Waking Staff: 32
Hot Water Temperature: 122.5
Fire Drill Date: Apr 21, 2023
Medication Expiry Date: Oct 11, 2023
Inspection Report
Follow-Up
Census: 44
Capacity: 73
Deficiencies: 6
Sep 20, 2023
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted due to an incident and fine, to verify the implementation of a previously submitted plan of correction.
Findings
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.
Deficiencies (6)
| Description |
|---|
| Failure to report medication administration errors to the Department within 24 hours as required. |
| Staff witnessed yelling at a resident and forcefully pushing the resident's legs in bed, violating dignity and respect requirements. |
| Medication record did not accurately reflect that a medication was not administered as prescribed. |
| Failure to follow prescriber's orders due to medication unavailability for over a month. |
| Medication error was not immediately reported to the resident, designated person, and prescriber. |
| Resident support plan was not updated to reflect recent psychological evaluation and related mental health concerns. |
Report Facts
License Capacity: 73
Residents Served: 44
Staffing Hours: 44
Waking Staff: 33
Hospice Residents: 1
Residents Age 60 or Older: 44
Residents with Physical Disability: 1
Inspection Report
Complaint Investigation
Census: 45
Capacity: 73
Deficiencies: 9
Jun 29, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation related to a medication error that caused a resident's death and other compliance concerns at Celebration Villa of Lewisburg.
Findings
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.
Complaint Details
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.
Deficiencies (9)
| Description |
|---|
| Failure to report incident to Department within 24 hours as required. |
| Medication error where Resident #1 was given Resident #2's medications causing death. |
| Resident #1's medical evaluation lacked weight and height information. |
| Failure to assist resident to secure medical care when health status declined. |
| Medication administration procedures not followed; medications pre-poured and administered to wrong resident. |
| Resident #2's medications were not administered but documentation falsely indicated they were. |
| Failure to follow prescriber's orders; medications administered to wrong resident. |
| Medication error was not immediately reported to resident, designated person, or prescriber. |
| Resident support plan did not address behaviors related to alcohol dependence and other issues. |
Report Facts
License Capacity: 73
Residents Served: 45
Staffing Hours: 47
Waking Staff: 35
Fine per day: 225
Inspection Report
Complaint Investigation
Census: 49
Capacity: 73
Deficiencies: 6
May 25, 2023
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulations and assess the submitted plan of correction.
Findings
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.
Complaint Details
The visit was complaint-related as indicated by the inspection information section. The plan of correction was reviewed and determined to be fully implemented.
Deficiencies (6)
| Description |
|---|
| Failure to report medication errors to the Department within 24 hours. |
| Staff did not respond timely to call bells for assistance, with delays up to 22 minutes. |
| Medication administration steps were not consistently followed; medications sometimes left in a cup for residents to take later. |
| Failure to notify prescriber regarding medication refusals within required timeframe. |
| Failure to follow prescriber's orders regarding medication administration and monitoring vital signs. |
| Medication error documentation and prescriber notification were incomplete. |
Report Facts
License Capacity: 73
Residents Served: 49
Current Residents in Hospice: 2
Staffing Hours - Total Daily Staff: 52
Staffing Hours - Waking Staff: 39
Residents Age 60 or Older: 49
Residents with Mobility Need: 3
Residents with Physical Disability: 1
Inspection Report
Complaint Investigation
Census: 48
Capacity: 73
Deficiencies: 10
Dec 7, 2022
Visit Reason
The inspection was conducted as a complaint and incident investigation to review compliance with regulations and assess the facility's plan of correction.
Findings
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.
Complaint Details
The inspection was triggered by a complaint and incident, as noted in the inspection information section.
Deficiencies (10)
| Description |
|---|
| The home only had 36.75 direct care staffing hours scheduled during waking hours instead of the required 39 hours. |
| Residents #1 and #2 had medications unlocked and accessible in their rooms without proper assessment for self-administration. |
| Resident #5 had a discontinued PRN medication present in the home. |
| Pharmacy labels for Resident #3 and Resident #4 medications did not include complete dosage or accurate directions. |
| Resident #5's blood glucose meter was shared between residents, risking communicable disease spread; several PRN medications were missing for residents #2, #3, and #5. |
| Resident #2 had unprescribed medications unlocked and accessible in their bedroom. |
| Resident #1's mobility assessment was inaccurate; resident requires physical assistance but was reported as independently mobile. |
| Resident #7 had not had an annual assessment and support plan completed. |
| Resident #1's support plan did not include a description of medical, dental, vision, hearing, mental health or behavioral care needs. |
| Resident #7's assessment and support plan was not signed by the assessor or resident, nor marked as refused or unable to sign. |
Report Facts
Residents served: 48
License capacity: 73
Direct care staffing hours required during waking hours: 39
Direct care staffing hours scheduled during waking hours: 36.75
Residents immobile: 4
Total direct care staffing hours required: 52
Total daily staff: 52
Waking staff: 39
Hospice current residents: 2
Residents age 60 or older: 48
Residents with mobility need: 4
Inspection Report
Complaint Investigation
Census: 53
Capacity: 73
Deficiencies: 0
Jul 27, 2022
Visit Reason
The inspection was conducted as a complaint investigation at Celebration Villa of Lewisburg on 07/27/2022.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Report Facts
Residents Served: 53
License Capacity: 73
Current Residents in Hospice: 2
Residents Age 60 or Older: 53
Residents with Mobility Need: 6
Inspection Report
Follow-Up
Census: 53
Capacity: 73
Deficiencies: 16
Jul 26, 2022
Visit Reason
The inspection was conducted as a follow-up to verify the implementation of a previously submitted plan of correction related to renewal, complaint, and incident reasons.
Findings
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.
Deficiencies (16)
| Description |
|---|
| Failure to notify the local area agency on aging within 24 hours of an incident of resident to resident abuse. |
| Failure to notify the Department within 24 hours of an incident of resident to resident abuse and medication error. |
| Resident records were unlocked, unattended, and accessible, breaching confidentiality. |
| Resident-home contract was not signed by the resident. |
| Resident room had an enabler bar attached to the bed without a cover, causing a safety hazard. |
| Telephone numbers for emergency services were not posted by phones in the hallway. |
| Resident room did not have access to a source of light that can be turned on/off at bedside. |
| Medical evaluations for residents did not indicate weight or mobility needs. |
| Medications and syringes were not kept locked; ointment was found unlocked and accessible. |
| Medications prescribed as needed were not available in the home. |
| Medication administration records did not indicate diagnosis or purpose for prescribed medications. |
| Medications prescribed were not administered because they were not available in the home. |
| No documentation of prescriber's response to medication errors in resident records. |
| Resident support plans did not indicate responsible party or address incidents. |
| Resident support plan was not signed by the resident nor documented refusal or inability to sign. |
| Resident records did not indicate identifying marks, if any. |
Report Facts
Total Daily Staff: 59
Waking Staff: 44
Residents Served: 53
Licensed Capacity: 73
Residents Age 60 or Older: 53
Residents with Mobility Need: 6
Inspection Report
Complaint Investigation
Census: 48
Capacity: 73
Deficiencies: 10
Apr 14, 2022
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with state regulations and verify the submitted plan of correction.
Findings
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.
Complaint Details
The visit was complaint-related as indicated by the reason for inspection and the unannounced nature of the visit.
Deficiencies (10)
| Description |
|---|
| Medication cart was observed unlocked and 3 resident medication record files unlocked on the laptop computer. |
| Direct care staff hours were insufficient to meet the required 2 hours per day for residents with mobility needs. |
| At least 75% of personal care service hours were not provided during waking hours. |
| Staffing was inadequate to safely evacuate residents in an emergency. |
| No fire drills were conducted in 2021 and 2022. |
| Fire drill records for two dates were incomplete, missing evacuation time and number of residents evacuated. |
| Medication cart was observed unlocked and unattended. |
| No activities were held or observed as scheduled after the Activities Director resigned. |
| Resident #1 did not have an assessment completed in 2021 as required. |
| Resident #1 and #2 support plans did not reflect current incontinent bowel and bladder needs. |
Report Facts
Residents served: 48
License capacity: 73
Residents with mobility needs: 3
Direct care hours provided: 48
Direct care hours required: 51
Completion date: Jul 31, 2022
Completion date: Jul 15, 2022
Completion date: May 9, 2022
Completion date: Aug 15, 2022
Completion date: Jun 30, 2022
Notice
Capacity: 73
Deficiencies: 0
Jun 22, 2021
Visit Reason
The document serves as a renewal notification for the operation of the Personal Care Home 'Elmcroft of Lewisburg' and informs that an onsite inspection will be conducted within the next twelve months as required by state regulations.
Findings
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.
Report Facts
Maximum licensed capacity: 73
Inspection Report
Renewal
Census: 34
Capacity: 73
Deficiencies: 4
Jun 2, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the facility license.
Findings
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.
Deficiencies (4)
| Description |
|---|
| Carbon Monoxide detector was located next to the gas fired fireplace and not 15 feet away as required. |
| Room #130 had bed canes with openings large enough to entrap resident's limbs, posing injury risk. |
| Doors leading to the interior courtyard were not marked as 'Not an Exit' though they were not exits. |
| First aid kit in the home’s 18 passenger bus lacked a breathing shield and eye covering. |
Report Facts
License Capacity: 73
Residents Served: 34
Total Daily Staff: 35
Waking Staff: 26
Current Hospice Residents: 1
Residents 60 Years or Older: 34
Residents with Mobility Need: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director/Administrator | Provided training related to deficiencies and plans of correction. | |
| Maintenance Manager | Received training on regulations and implemented corrective actions. | |
| Maintenance Director | Posted 'Not an Exit' signage as part of plan of correction. | |
| Nurse | Updated first aid kit with required items. | |
| Healthy Lifestyles Director | Received training on first aid kit regulation. |
Inspection Report
Renewal
Deficiencies: 0
Jan 20, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
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