Celebration Villa of Lewisburg.

“Staff person A verbally abused a resident, and this abuse incident was not reported to the Area Agency on Aging in a timely manner. The facility failed to immediately report suspected abuse in accordance with the Older Adult Protective Services Act and regulatory requirements.”

“An incident of verbal abuse by staff person A was not reported to the Department of Human Services within 24 hours. Additionally, a power outage affecting the secured dementia unit door locking devices (lasting less than 30 minutes) and resulting emergency measures to prevent elopements were not reported to the Department.”

“Staff person A verbally abused a resident by repeatedly addressing the resident with derogatory slurs throughout the night, violating the requirement that residents be treated with dignity and respect.”

“Fire exit routes were obstructed: a chair was blocking the fire exit door in the dining room, and a large trash can was blocking a hallway fire exit door at the front of the facility. Stairways, hallways, and egress routes must remain unlocked and unobstructed.”

“Resident #3, who is incontinent and requires staff assistance for incontinence care, was found by family on multiple occasions in saturated and soiled incontinence briefs with soiled linens, constituting neglect.”

“Carbon monoxide detector batteries near break room were last replaced in September 2023, exceeding the annual replacement requirement. Carbon monoxide detector near Room #120 batteries were not dated to indicate when they were last changed. The Care Facility Carbon Monoxide Alarm Standards Act requires annual battery replacement.”

“Resident #2 requires total assistance showering and 2-staff assists with transfers per RASP, but does not receive weekly showers due to staff shortage. On 2/23/25 resident fell while exiting shower with only one staff present and hit head. On 1/13/25 call bell went unanswered for 19 minutes 41 seconds; resident fell attempting toileting without assistance and hit head, requiring hospitalization. Call bell logs show excessive wait times (up to 679 minutes). Residents #1, #2, #5, #6, and #7 in SDCU require 2-person assists but are not receiving regular showers due to insufficient staffing.”

“The home failed to provide adequate personal hygiene care and monitoring for a resident who experienced health decline in January 2025. The resident was frequently found soiled with urine or feces, food trays were left uneaten and stacking in the room, and overnight bladder management checks were not consistently performed despite the resident's documented need for this care.”

“Medications were found left in a resident's room on three separate occasions, including on the resident's window sill. Staff reported handing medications to the resident at the door rather than administering them directly because the resident would not allow staff entry due to a pet.”

“The resident assessment and support plan was not updated timely to reflect the resident's health decline in January 2025 that required more frequent toileting checks and feeding assistance. One resident's annual support plan was not completed until after a report of need investigation. Another resident's assessment was overdue and annual support plan was never completed.”

“A resident support plan was not signed by the staff person who completed the form as required.”

“A resident screamed from their bedroom and multiple staff members reported observing a staff member towering over the resident, screaming at them, and the resident alleged the staff member grabbed them and put their hand around their neck. The resident stated they were scared and afraid.”

“The home failed to submit incident reports to the Department within 24 hours for two medication errors: Resident #1 did not receive prescribed atorvastatin, eliquis and melatonin on 7/16/24 at 9pm; Resident #2 did not receive prescribed Mirabegron tab 25mg ER daily from 7-4-24 to 7-6-24. This was a repeat violation from 9/20/23.”

“The gate to the home's proposed secured dementia care unit courtyard, which exits to the back area of the home, was locked, obstructing egress routes from the unit. This was a repeat violation from 2/7/24.”

“The home's emergency evacuation diagram did not include the newly created exit to the proposed secured dementia care unit courtyard.”

“No exit sign was posted at the exit from the proposed memory care unit that leads to an enclosed courtyard with a gate. This was a repeat violation from 2/7/24.”

“On 7-12-24, Resident #1's medication administration record documented refusal of AM medications (Eliquis, Escitalopram, Lisinipril and Metoprol), but the home could not provide documentation that the resident's physician was informed of the refusal within 24 hours as required.”

“A resident was left with overhead light on as punishment after refusing to give staff a powder, and was later frisked by staff to locate the powder. Staff member also cursed at the resident. The resident required one-person assist to transfer and could not turn off the light themselves.”

“The preadmission screening form for Resident #1 was not dated when completed and did not indicate whether the resident was able to safely use and avoid poisonous materials.”

“Resident's support plan documented regular diet but a physician's order indicated the resident was changed to a mechanical soft diet, creating a discrepancy in current documentation. Additionally, information regarding incontinence, use of incontinence briefs, and physical assist requirements was not documented in the most current support plan.”

“Staff persons A, B, and C did not receive annual training in fire safety completed by a fire safety expert or by a staff person trained by a fire safety expert during training year 2023.”

“The illuminated exit sign directly in front of exit door C was not connected to the ceiling anchor and was hanging only by electrical wires.”

“The bedside lamp for Resident #1 was without a light bulb leaving no operable light available bedside for the resident.”

“Two of the four exit doors in the activity room were obstructed by chairs and tables preventing immediate egress through those exits to the outside of the building.”

“There were three exits leading from the activity room to the outside that did not have an exit sign posted near them.”

“During med cart audit on 02/07/24, a loose pill was discovered in cart 2, drawer 2, which could not be identified.”

“Resident #2 was administered a second dose of medication at an incorrect time. The medication is prescribed to be administered in the morning and at bedtime. The home did not follow the prescriber's orders. This is a repeat violation from 9/20/23, 6/29/23, and 5/25/23.”

“The most recent RASP for Resident #4 was not updated to reflect a physician order that allows the resident to self-administer two of their medications bedside. This is a repeat violation from 9/20/23, 6/29/23, and 12/7/22.”

“Resident home contracts for two residents were not signed by the residents. This was a repeat violation from 7/26/22.”

“The home did not have verification of a High School Diploma, GED, or active Nursing Aide Assistant registry for a staff member hired in 2023.”

“Resident #3 had a halo safety ring attached to the bed that was not securely attached, causing movement from side to side and posing a safety hazard. This was a repeat violation from 7/26/22.”

“A hot water temperature of 122.5 degrees was measured in the bathroom of room 113, exceeding safe standards.”

“A used dryer sheet and a sock were found behind the dryer in the laundry room, posing a potential fire hazard by storing combustible materials near heat sources.”

“A fire drill record from 4/21/23 was incomplete, lacking documentation of evacuation time, exit routes used, number of residents, number evacuated, staff participating, whether alarm was activated and operative, problems encountered, and planned corrective actions.”

“Medical Evaluation documentation for Resident #2 was missing height and weight information. Medical Evaluation documentation for Resident #4 was missing the evaluation date. This was a repeat violation from 6/29/23.”

“Medication errors (lorazepam not administered on 8/1/23 and 8/2/23) were not reported to the Department within 24 hours as required. This was a repeat violation.”

“Staff person was witnessed yelling at and forcefully pushing a resident's legs in bed on 8/13/23, violating the requirement that residents be treated with dignity and respect.”

“Medication Administration Record for Resident #3 was signed indicating Vitamin D3 was given on 8/18/23, but notes on back stated 'do not have,' and the proper symbol and notation were not used to document the medication was not administered.”

“Florastor cap 250mg prescribed twice daily was not available in the home and was not administered from 8/4/23 to 9/5/23, resulting in failure to follow the prescriber's orders. This was a repeat violation.”

“Medication error for Resident #4 (Florastor cap 250mg not administered from 8/4/23 to 9/5/23) was not immediately reported to the physician; physician was not notified until 9/7/23. This was a repeat violation.”

“Resident #5's Assessment and Support Plan was not updated after an incident on 4/21/23 when the resident was sent to the ED for threatening self-harm and undergoing psychological evaluation. The current plan did not document agitation, aggression, mental health concerns, or evaluation results. This was a repeat violation.”