Inspection Reports for Celebration Villa of Shippensburg
129 Walnut Bottom Road Shippensburg, PA 17257, PA, 17257
Back to Facility ProfileDeficiencies per Year
8
6
4
2
0
Unclassified
Census Over Time
Census
Capacity
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
| Name | Title | Context |
|---|---|---|
| Megan Herwig | MT-BC, Director of Resident Engagement for Priority Life Care | Named 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
| Name | Title | Context |
|---|---|---|
| Executive Director | Named in relation to fire drill record deficiencies, training, and corrective actions | |
| Maintenance Director | Named in relation to fire drill record deficiencies, training, and corrective actions |
Inspection Report
Renewal
Census: 39
Capacity: 62
Deficiencies: 3
Aug 3, 2022
Visit Reason
The inspection was conducted as a renewal visit to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to have deficiencies related to missing resident contract signatures, improper medication storage with loose pills found, and incomplete documentation of mobility needs for a resident. Plans of correction were accepted and implemented with follow-up monitoring scheduled.
Deficiencies (3)
| Description |
|---|
| Resident contract for Resident 1 did not have the resident's signatures or date signed on the contract. |
| Medication cart had two loose pills inside the cart drawers. |
| Resident 2's most recent RASP lacked documentation of mobility needs despite physician orders. |
Report Facts
License Capacity: 62
Residents Served: 39
Current Hospice Residents: 3
Total Daily Staff: 42
Waking Staff: 32
Residents with Mobility Need: 3
Residents with Physical Disability: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in medication storage deficiency and plan of correction. |
| Executive Director | Executive Director | Obtained missing resident contract signature for Resident 1. |
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
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter. |
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