Inspection Reports for Celebration Villa of Shippensburg

129 Walnut Bottom Road Shippensburg, PA 17257, PA, 17257

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Inspection Report Census: 53 Capacity: 62 Deficiencies: 0 Apr 1, 2025
Visit Reason
The inspection was conducted as a licensing inspection due to an incident, with an unannounced partial inspection type.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 53 License Capacity: 62 Current Residents in Hospice: 4 Residents Age 60 or Older: 53 Residents with Mental Illness: 1 Residents with Mobility Need: 5
Inspection Report Complaint Investigation Census: 51 Capacity: 62 Deficiencies: 7 Dec 18, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation, as indicated by the unannounced partial inspection on 12/18/2024.
Findings
The inspection found multiple violations including failure to report an incident timely, verbal and physical abuse among residents, incomplete medical evaluations within required timeframes, unsecured medications, and incomplete preadmission screening forms. Corrective actions and staff education were implemented with ongoing monitoring.
Complaint Details
The visit was complaint-related, investigating incidents of verbal and physical abuse involving staff and residents. The investigation substantiated the abuse allegations and other regulatory violations.
Deficiencies (7)
Description
Failure to report an incident to the department within 24 hours as required.
Resident subjected to verbal abuse by staff member using inappropriate language.
Physical altercations between residents including hitting, biting, and clawing.
Medical evaluations not completed within 60 days prior to admission or within 30 days after admission for residents.
Prescription medications and syringes were not kept locked and were accessible.
Discontinued medication was found accessible in the facility.
Preadmission screening form was completed after the resident's admission date.
Report Facts
License Capacity: 62 Residents Served: 51 Current Residents in Hospice: 5 Resident with Mobility Need: 15 Waking Staff: 50 Total Daily Staff: 66
Employees Mentioned
NameTitleContext
Megan HerwigMT-BC, Director of Resident Engagement for Priority Life CareNamed as conducting dementia training for staff on 1/15/2025.
Inspection Report Renewal Census: 47 Capacity: 62 Deficiencies: 2 Nov 1, 2023
Visit Reason
The inspection was conducted as a renewal visit to review the facility's compliance with licensing requirements.
Findings
The submitted plan of correction was determined to be fully implemented. However, deficiencies were found related to fire drill records and evacuation times exceeding the safe evacuation time specified by a fire safety expert.
Deficiencies (2)
Description
Fire drill records did not document the total number of residents evacuated and some drills exceeded the evacuation time due to difficulties with immobile residents and resident non-participation.
The home exceeded the safe evacuation time during multiple fire drills, with evacuation times ranging from 6 minutes 20 seconds to 13 minutes, exceeding the expert-specified safe evacuation time of 4 minutes 37 seconds.
Report Facts
License Capacity: 62 Residents Served: 47 Fire Drill Evacuation Time: 13 Fire Drill Evacuation Time: 7 Fire Drill Evacuation Time: 7.58 Fire Drill Evacuation Time: 6.33 Fire Drill Evacuation Time: 9.93 Safe Evacuation Time: 4.62 Total Daily Staff: 51 Waking Staff: 38
Employees Mentioned
NameTitleContext
Executive DirectorNamed in relation to fire drill record deficiencies, training, and corrective actions
Maintenance DirectorNamed in relation to fire drill record deficiencies, training, and corrective actions
Notice Capacity: 62 Deficiencies: 0 May 14, 2021
Visit Reason
The document serves as a renewal notification and license issuance for the Personal Care Home 'Elmcroft of Shippensburg' following receipt of the renewal application dated March 2, 2021.
Findings
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.
Report Facts
Maximum licensed capacity: 62
Employees Mentioned
NameTitleContext
Jamie L. BuchenauerDeputy Secretary, Office of Long-term LivingSigned the renewal notification letter.
Report Aug 3, 2022
File
20220803_33375.pdf

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