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F0658
D

Unlicensed Staff Administered Medications and Treatments

Williamsport, Pennsylvania Survey Completed on 12-23-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that care and services were provided in accordance with professional standards of quality for three residents. On a specific date, a nurse aide (NA) administered prescribed medications and performed medical treatments, including oral, PEG tube, and subcutaneous medication administration, as well as a dressing change, for three residents. These actions were performed on behalf of a licensed practical nurse (LPN), who was aware of and facilitated the NA's involvement in medication administration and treatment procedures. The NA's actions included administering oral medications and subcutaneous insulin to one resident, administering medications via PEG tube and subcutaneous insulin to another, and completing a dressing change on a surgical site for a third resident. Pennsylvania regulations require specialized training and credentialing for medication administration, which the NA did not possess. Resident interviews and facility documentation confirmed that the NA performed these tasks, and the LPN acknowledged facilitating the NA's actions. The incident was discovered and reported to the Director of Nursing (DON) several days later. The facility's failure to ensure that only appropriately licensed and credentialed staff administered medications and performed medical treatments resulted in a breach of professional standards of quality for the affected residents.

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