Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Homewood Living Williamsport during CMS and state inspections, most recent first.
A resident who was alert, oriented, and able to communicate needs was observed after activating the call light, but an GNA entered the room without knocking or requesting permission. The GNA confirmed she did not knock and said she wanted to answer the light. The DON stated staff were expected to knock and introduce themselves before attending to the call light.
A resident with moderate cognitive impairment and dependence for most self-care needs was observed in bed with the call device clipped to the side of the bed and out of reach. The resident said reaching the call light was sometimes challenging, and a later observation again found the call bell unreachable despite the care plan directing staff to keep it within reach.
Failure to Identify and Document Resident Grievances: Surveyors found repeated resident council concerns about call bell response times, delayed care, food issues, bed linen changes, and staff not identifying themselves, but the grievance log showed no meaningful grievance tracking for the year. Staff described grievances as concerns repeated in council meetings, yet the documented log contained only one unclear entry with no details, investigation, or resident-specific follow-up.
A facility interfered with residents’ right to file grievances by not maintaining a functional grievance process. Resident complaints about call bell response times, food, linen changes, and staff entering rooms without identifying themselves were handled informally by activities staff instead of being processed as grievances. The grievance log had no documented grievances for the year except for one incomplete entry, and staff said concerns were only escalated if repeated by more than one resident.
Failure to Provide Activities Based on Resident Assessment: A resident with normal cognition stated they felt trapped and never got to go outside. The resident’s care plan called for encouragement to go outdoors when weather permitted, but EHR activity charting showed only 4 documented outdoor activities for the year. The AD and activity assistant said the resident sometimes refused outdoor activities, but those refusals were not documented.
A resident with an order for oxygen at 2 L/min for hypoxia was observed receiving oxygen via nasal cannula at 4 L/min on multiple survey observations. The head nurse confirmed the concentrator was set at 4 L/min and then changed it to 2 L after the surveyor intervened.
Incomplete pain management documentation was found for a resident with chronic pain-related diagnoses and a PRN narcotic order. The eMAR showed multiple medication administrations with missing pain scores, missing follow-up assessments, and one dose without documented pain characteristics, and there was no documentation that non-pharmacological interventions were attempted before the medication was given. The DON stated nurses were responsible for documenting pain management, and an IP nurse review confirmed the missing documentation across all administrations.
Failure to implement EBP and PPE for residents with wounds. Staff provided direct care to a resident with a draining sacral wound without wearing gowns, and EBP signage and gown supply were not initially present outside the room. A second resident with a chronic stage 3 sacral pressure ulcer was not placed on EBP because staff believed multiple criteria had to be met and cited cost concerns, despite the facility policy requiring gowns and gloves for residents with wounds during high-contact care.
A resident in a LTC facility suffered a fall with a major injury due to an error in medication administration. The resident, recovering from orthopedic surgery, was over-administered Ambien, leading to lethargy and a fall. The error occurred when a nurse failed to discontinue a one-time dose of Ambien, resulting in the administration of both the standing and one-time doses. The incident was confirmed by the DON, who identified the root cause as a transcription error.
A cognitively impaired resident in an LTC facility was not protected from physical abuse by a staff member. The resident reported not wanting to be hit anymore, leading to the discovery of bruises on their body. An LPN found the bruises and linked them to a GNA who admitted to bumping the resident while cleaning barrier cream. The DON confirmed the GNA's admission and observed the bruises, which matched the shape of the resident's glasses.
Two residents in an LTC facility experienced significant medication errors. One resident suffered a fall with major injury due to an over-administration of sleep medication, while another received the wrong dosage of pain medication. The errors were attributed to transcription and administration mistakes by nursing staff, highlighting lapses in medication administration and documentation processes.
The facility failed to offer pneumococcal vaccinations in line with CDC recommendations, affecting eight residents. The facility did not have PCV20 available and did not identify this as a potential deficient practice. Despite the Consultant Pharmacist raising the issue in QA meetings, it was not addressed, and the Medical Director was unaware that PCV20 had not been ordered.
The QA committee at the facility failed to implement CDC recommendations for the Prevnar20 vaccine, despite being informed by the Consultant Pharmacist. Staff turnover in the Infection Preventionist position and lack of vaccine orders contributed to this oversight. Interviews revealed that key staff were unaware of the vaccination guidelines, indicating a gap in the facility's quality assurance processes.
The facility did not provide gowns for laundry staff handling soiled linens, only gloves were used. The Director of Housekeeping/Laundry stated there was no contact with soiled laundry, and the Infection Preventionist was unaware of the lack of gowns. The facility's policy required both gloves and gowns for handling soiled laundry.
The facility failed to offer pneumococcal vaccinations to eight residents over the age of 65, as required by CDC guidelines and facility policy. Interviews with staff revealed systemic issues, including a lack of orders for the PCV20 vaccine and no alerts in the EMR system to prompt nursing staff to obtain a physician's order. The Medical Director acknowledged the importance of offering the PCV20 vaccine, but the facility lacked a systematic approach to ensure residents received necessary vaccinations.
The facility did not ensure that five staff members, including GNAs, an LPN, and an RN, were trained in the QAPI Program as required by their policy. The DON confirmed the lack of training, attributing the delay to the COVID-19 pandemic.
A resident received an over-administration of Ambien due to a transcription error by a nurse who failed to discontinue a one-time dose order. This resulted in the resident receiving both the standing and one-time doses on multiple occasions, as confirmed by the medication administration record and the Director of Nursing.
A resident in an LTC facility experienced a fall due to over-administration of Ambien, as a nurse failed to discontinue a one-time dose after administration. This resulted in the resident receiving both the standing and one-time doses, leading to lethargy and a fall. The incident was confirmed by the DON and highlighted during a complaint survey.
A resident received an over-administration of Ambien due to a transcription error by a nurse who failed to discontinue a one-time dose order. This resulted in the resident receiving both the standing dose and the one-time dose on multiple occasions, as confirmed by the MAR and the DON.
A facility failed to transmit a resident's discharge MDS data to CMS within the required timeframe. The resident, admitted with congestive heart failure and pneumonia, was discharged to another facility. The MDS Coordinator did not submit the completed MDS due to a lack of notification from the EMR system and absence of an auditing process. The DON expected timely submission per the RAI Manual.
A resident continued to receive an unnecessary dosage of metformin despite a consultant pharmacist's recommendation and the physician's agreement to reduce the dosage. The facility's process for updating medication orders was not followed, leading to the resident receiving the higher dosage for an extended period.
The facility reported a medication error rate of 5.13% due to two incidents. One involved a resident with diabetes who received insulin without proper priming and timing, as the LPN was not trained in the correct procedure. Another resident with a duodenal ulcer missed a dose of sucralfate because the RN could not find the medication card, which was incorrectly placed in the cart. The DON confirmed the medication was available and should not have been missed.
Two residents received incorrect medication doses due to inadequate staff training. A resident was given the wrong dose of oxycodone because a CMA pulled the wrong medication card, while another resident with diabetes received insulin incorrectly as an LPN was not trained on proper insulin pen use. The facility lacked evidence of proper training and observation for these staff members.
Failure to Knock Before Entering Resident Room
Penalty
Summary
The facility failed to treat a resident with respect and dignity when Staff #7, a geriatric nurse aid, entered Resident #68's room in response to a call light without knocking on the door or requesting permission before entering. During the observation, the resident had activated the call light for help, and Staff #7 went into the room without first announcing herself. When asked, Staff #7 confirmed that she did not knock and stated that she simply wanted to answer the light. Record review later showed that Resident #68 was alert, oriented, able to communicate his/her needs, and able to understand others. The DON was informed of the concern and stated that staff were expected to knock on residents' doors and introduce themselves before attending to the call light.
Call Device Kept Out of Reach
Penalty
Summary
The facility failed to ensure that a resident's call device was kept within reach. Resident #9 had moderate cognitive impairment and was dependent on staff for most self-care needs according to the MDS. During an observation, the resident was lying in bed with the call device clipped to the side of the bed and was unable to reach it when asked to do so. The resident stated that reaching the call device was sometimes challenging. The care plan included a direction to keep the call light within the resident's reach, yet a later observation again showed the call bell clipped to the side of the bed and unreachable. A unit manager present in the room confirmed that the call device was not within the resident's reach and repositioned it after the surveyor pointed it out.
Failure to Identify and Document Resident Grievances
Penalty
Summary
The facility failed to ensure residents' grievances were identified, investigated, documented, and responded to. During review of the resident council meeting minutes for 2025, surveyors found repeated resident concerns about call bell response times, delayed assistance getting out of bed, food temperature and food preferences, bed linen change frequency, and staff not always identifying themselves when entering rooms. Staff stated that a concern was considered a grievance only if it came up more than once in resident council meetings, and that repeated concerns would be escalated to the grievance officer or the DON. When the surveyor requested the grievance logs for the prior 12 months, Staff #13, identified as the grievance officer, stated there had been no grievances for all of 2025. However, the binder provided contained grievance logs for 2024, 2025, and 2026, and only one entry was present, dated 12/14/2025, with no details about the nature of the grievance and no clear documentation of who submitted it or how it was resolved. The resident council minutes showed multiple concerns that had been discussed over several months, but these concerns were not reflected in the grievance log or supported by documentation showing investigation or follow-up through the grievance process. Staff #12 explained that some concerns were written down and given to the DON, and the DON stated she addressed some concerns directly with residents on the unit, including telling them they could request bed linen changes whenever they preferred. The NHA described grievances broadly as any concern a resident or representative felt was not adequately addressed, including cold food, cleanliness, and medications, but the facility's grievance log and documentation did not show that the resident council concerns were handled through the grievance process. The facility policy stated grievances should be investigated by Social Services, reported to the administrator, and communicated back to the resident or representative, but no evidence was provided that these steps occurred for the concerns identified in the resident council minutes.
Failure to Maintain a Functional Grievance Process
Penalty
Summary
The facility interfered with residents’ right to voice grievances without discrimination or reprisal by failing to maintain and implement a functional grievance process. Review of Resident Council meeting minutes, grievance logs, facility policy, and staff interviews showed that resident complaints were screened by activities staff and handled informally without being recognized or processed as grievances. Resident Council minutes from January through December 2025 documented complaints about call bell response times, food temperature and preferences, frequency of bed linen changes, and staff entering resident rooms without identifying themselves. The grievance log contained no grievances for 2025 except for one incomplete entry dated 12/14/2025 with inconsistent resolution dates and no documentation of investigation or the response provided. Staff stated resident concerns were only escalated as grievances if they were repeated more than once and raised by more than one resident, which prevented individual resident complaints from being formally filed, investigated, documented, or responded to.
Failure to Provide Activities Based on Resident Assessment
Penalty
Summary
The facility failed to provide activities to residents based on their comprehensive assessment to support physical, mental, and psychosocial well-being for 1 of 3 residents reviewed for activities. Resident #3, who had been in the facility since early 2022, stated during interview that they were "trapped like prisoners" and never got to go out. The resident’s most recent annual comprehensive assessment, with a reference date of 9/3/25, indicated normal cognitive status and that it was very important for the resident to go outside to get fresh air when the weather was good. The resident’s activity care plan included the intervention to invite and encourage the resident to go outside when weather permitted. Review of the electronic health record activity charting for 2025 showed only 2 documented outdoor group activities and 2 documented outdoor individual activities for the entire year. During interview, the Activity Director and an activity assistant stated that there were many outdoor activities, especially in the summer, and reported that the resident sometimes refused to attend or join outdoor activities, but those refusals were not documented. They acknowledged that the record reflected only 4 instances of outdoor activities for the resident during 2025 despite the assessment showing the importance of going outside.
Oxygen Flow Rate Did Not Match Physician Order
Penalty
Summary
The facility failed to follow an attending physician’s order for oxygen therapy for Resident #94. The resident had an order initiated on 12/23/25 for oxygen at 2 L/min every shift for hypoxia, but during survey observations on 1/5/2026 and 1/6/2026 the resident was seen lying in bed receiving oxygen via nasal cannula connected to an oxygen concentrator set at 4 L/min. During an interview on 1/6/2026, the head nurse for the second-floor unit confirmed the oxygen flow rate was set to 4 L/min in the resident’s room and then stated the resident should receive 2 L of oxygen, changing it from 4 L after the surveyor’s intervention.
Incomplete Pain Management Documentation
Penalty
Summary
Safe, appropriate pain management was not provided for a resident with diagnoses including lumbar radiculopathy, left shoulder pain, and a rupture/tear of the left shoulder rotator cuff. The resident had an order for a narcotic pain medication to be given as needed for pain, and the eMAR showed it was administered 14 times in December 2025. Documentation in the eMAR included nurse notes with pain scores before medication administration and follow-up pain scores for some doses, but several administrations were incomplete: one dose lacked both pre- and post-medication pain scores, one lacked a follow-up pain score, one lacked pain characteristics such as score, severity, and location, and one lacked a follow-up pain score. A later record review found no documentation that non-pharmacological interventions were attempted or provided before the PRN pain medication was given. The facility's pain management policy stated that physicians order appropriate non-pharmacological interventions and that staff provide a comforting environment and appropriate physical and complementary interventions. The DON stated that nurses were primarily responsible for documenting pain management, including non-pharmacological interventions, and the IP nurse's review confirmed that all 14 administrations lacked documentation of non-pharmacological interventions and identified the missing pain assessment documentation noted above.
Failure to Implement EBP and PPE for Residents With Wounds
Penalty
Summary
The facility failed to develop and implement infection prevention and control policies and procedures, as evidenced by staff not wearing appropriate PPE before providing direct care to residents who met criteria for Enhanced Barrier Precautions (EBP). The deficiency was identified through interviews, observations, and record reviews involving two residents with pressure ulcers. The facility’s infection control policy stated that EBP required gloves and gowns before high-contact resident care activities for residents with wounds and/or indwelling medical devices. Resident #13 had a facility-acquired sacral wound that was documented as increasing in size and draining, with provider orders for daily wound dressings. During multiple observations, staff provided direct care and wore gloves but did not wear gowns. Staff also did not have EBP signage posted on the resident’s door or gowns available outside the room during the earlier observations. A head nurse confirmed the resident had a wound but was unsure whether EBP was indicated, and the infection prevention nurse stated that signage and gowns should have been in place for the resident. Resident #12 had a stage 3 sacral pressure ulcer and a chronic wound documented in the medical record, but there was no order or documentation showing that EBP had been initiated when the wound was discovered. During interviews, the wound nurse, DON, and infection prevention nurse stated that the resident was not placed on EBP because the dressing was intact, there was no heavy drainage, the wound was covered by clothing, and there was no history of infection. They also stated that they believed several criteria had to be met before EBP was used, including wound drainage, infection history, chronicity, and wound size. On a later tour, an EBP sign and storage for gowns and gloves were observed outside the resident’s room.
Medication Error Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to protect a vulnerable resident from a fall with a major injury due to an error in medication administration. The resident, admitted for rehabilitation after orthopedic surgery, experienced a fall resulting in a fracture near the left eye. The fall occurred while the resident was being assisted to the bathroom by a GNA and was attributed to the over-administration of the sleep medication Ambien. The error stemmed from a failure to delete an incorrect order for a one-time dose of Ambien from the resident's medical record, leading to the administration of both the standing dose and the one-time dose. The incident was investigated, revealing that RN #307 transcribed a provider order for a one-time dose of Ambien but failed to discontinue it after administration. Consequently, RN #308 administered both the standing dose and the one-time dose, resulting in the resident's lethargy and subsequent fall. The Director of Nursing confirmed these findings, and the facility identified the root cause as the over-administration of Ambien due to the transcription error.
Failure to Protect Resident from Abuse by Staff Member
Penalty
Summary
The facility failed to protect a cognitively impaired resident from physical abuse by a staff member. The incident involved a resident who was memory-impaired and had been assessed as such in their quarterly Minimum Data Set (MDS) assessment. On the day of the incident, the resident approached a Licensed Practical Nurse (LPN) and expressed a desire not to be hit anymore. Upon further investigation, the LPN discovered the resident had purple/red bruises on various parts of their body, including the right temple, right eyebrow, and hands. The investigation revealed that a Geriatric Nursing Assistant (GNA) admitted to having bumped the resident while attempting to clean barrier cream from the resident's face. The Director of Nursing (DON) confirmed the GNA's admission and observed the bruises, which were consistent with the shape of the resident's glasses. The LPN had initially thought the resident was involved in a resident-to-resident altercation but later realized the injuries were likely caused by the GNA's actions. The facility's Human Resource Director confirmed that the GNA's last day of work was the day of the incident. The LPN ensured the resident was not left alone until the DON arrived to remove the GNA from the unit. The surveyor expressed concern to the facility's administration about the failure to protect the resident from abuse, which was evident during the complaint survey.
Medication Errors Lead to Resident Harm
Penalty
Summary
The facility failed to protect two residents from significant medication errors, resulting in harm to one of them. Resident #901, admitted for rehabilitation after orthopedic surgery, experienced a fall with a major injury due to an over-administration of sleep medication. The error occurred when RN #307 transcribed a one-time dose of Ambien and failed to discontinue it after administration. Subsequently, RN #308 administered both the standing dose and the one-time dose, leading to the resident's lethargy and fall. Resident #174, who was cognitively intact and had a history of occasional pain, was administered the wrong dosage of pain medication. CMA1 mistakenly pulled the medication card for another resident and administered Oxycodone 5 mg instead of the prescribed 2.5 mg. This error was discovered during a shift change count when LPN7 noticed a discrepancy in the medication card. The Director of Nursing confirmed the error and noted that the resident did not experience any adverse reactions. The facility's policy on administering medications requires that medications be given safely and as prescribed, with proper documentation. However, in both cases, the nursing staff failed to adhere to these guidelines, leading to significant medication errors. The incidents highlight lapses in medication administration and documentation processes within the facility.
Failure to Implement CDC-Recommended Pneumococcal Vaccinations
Penalty
Summary
The facility's administration failed to implement its Resident Immunization policy in accordance with current CDC recommendations, specifically regarding the provision of pneumococcal vaccinations. Eight residents were not offered the Prevnar (PCV20) or PCV15 vaccines as recommended by the CDC. The facility did not have PCV20 available and failed to identify this as a potential deficient practice in their quality assurance processes. This oversight was identified through record reviews, staff interviews, and policy reviews. Interviews with facility staff revealed that the Consultant Pharmacist had raised the issue of PCV20 vaccinations during Quality Assurance meetings, but it was not addressed by the members. The Medical Director confirmed awareness of the CDC recommendations but was unaware that the facility had not ordered the PCV20 vaccine. The Director of Nursing was also unaware of why the PCV20 was not identified as a potential deficient practice. These failures had the potential to increase the risk of residents contracting pneumonia.
Failure to Implement Prevnar20 Vaccination Recommendations
Penalty
Summary
The Quality Assessment (QA) committee at the facility failed to identify and address deficiencies in the infection control program, specifically regarding the administration of the Prevnar (PCV) 20 vaccine. Despite the Consultant Pharmacist providing the QA committee with the Centers for Disease Control and Prevention (CDC) recommendations for the Prevnar20 vaccine during a meeting in 2022, the facility did not implement these recommendations. The Consultant Pharmacist noted that there was staff turnover in the Infection Preventionist position, and she was not asked to assist with tracking pneumococcal vaccines for the current resident population. Additionally, the facility had not placed any orders for the PCV20 vaccine, indicating a lack of follow-through on the CDC guidelines. Interviews with facility staff revealed a lack of awareness and action regarding the Prevnar20 vaccination recommendations. The Director of Nursing (DON) was unsure why the CDC recommendations were not addressed in the QA meetings, and a Registered Nurse (RN) who attended the meetings did not recall the Consultant Pharmacist discussing the vaccination guidelines. The facility's Quality Assurance Program document from 2012 outlined the need for an ongoing program to monitor and improve resident care quality, yet the failure to implement the Prevnar20 vaccination recommendations suggests a gap in the facility's quality assurance processes.
Failure to Provide PPE for Laundry Staff
Penalty
Summary
The facility failed to ensure that personal protective equipment (PPE) was available for laundry staff in the laundry room while sorting soiled resident clothing and bed linens. During a tour of the soiled laundry room, it was observed that gloves were available, but gowns were not. Housekeeper 1 confirmed that she only used gloves and did not don a gown when handling soiled linens. The Director of Housekeeping/Laundry (DHL) stated that the laundry staff retrieved bagged soiled laundry from a bin and placed the bag open end first into the washing machine, claiming there was no contact between the soiled laundry and the staff. The Director of Nursing (DON) confirmed that only gloves were used by the laundry staff. The Infection Preventionist (IP) was unaware that gowns were not being used, as she did not enter the soiled laundry room. The facility's policy on handling soiled laundry, dated September 2022, indicated that standard precautions, including the use of gloves and gowns, should be followed when sorting soiled laundry.
Failure to Offer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer pneumococcal vaccinations to eight residents, as required by CDC guidelines and the facility's own policy. The residents, all over the age of 65, were not provided the opportunity to receive the PCV20 vaccine, which is recommended for adults in this age group. The facility's policy mandates that residents be offered immunizations upon admission or shortly thereafter, but this was not adhered to, as evidenced by incomplete or missing documentation in the residents' medical records. Interviews with facility staff, including the Consultant Pharmacist, Infection Preventionist, and Admission Coordinator, revealed systemic issues in the vaccination process. The Consultant Pharmacist confirmed that no orders for the PCV20 vaccine were placed by the facility. The Infection Preventionist noted that the immunization records did not reflect the administration of the PCV20 vaccine, and the Admission Coordinator was unaware of any alerts in the electronic medical records system to prompt nursing staff to obtain a physician's order for the vaccine. The Medical Director acknowledged the importance of offering the PCV20 vaccine as the standard for long-term care facilities. However, the Director of Nursing from a sister facility confirmed that there were no triggers in place to alert clinical staff to the need for a physician's order for the pneumococcal vaccine. This lack of a systematic approach to ensure residents are offered the necessary vaccinations contributed to the deficiency identified in the survey.
Failure to Train Staff on QAPI Program
Penalty
Summary
The facility failed to ensure that five staff members, including three Geriatric Nursing Assistants (GNAs), one Licensed Practical Nurse (LPN), and one Registered Nurse (RN), were trained in the facility's Quality Assurance Performance Improvement (QAPI) Program. The facility's policy, dated May 2019, mandates that all personnel participate in initial orientation and regularly scheduled in-service training classes, which include training on the elements and goals of the facility's QAPI program. However, a review of the training records from the Relias online training program revealed that none of the five staff members had received training on the QAPI program. During an interview, the Director of Nursing (DON) confirmed that the staff had not been trained on the QAPI program, citing the onset of COVID-19 as a reason for the delay in implementing the training.
Medication Order Error Leads to Over-Administration of Ambien
Penalty
Summary
The facility failed to maintain an accurate medication order history for a resident, which led to the over-administration of the prescribed sleep medication, Ambien. The issue was identified during a complaint survey, where it was found that a nurse transcribed a provider order for a one-time dose of 12.5mg Ambien but did not discontinue the order after administration. This resulted in the resident receiving both the standing dose of 6.25mg and the one-time dose of 12.5mg on multiple occasions. The medication error was confirmed through a review of the resident's medication administration record for September 2022, which showed the one-time dose was administered on three consecutive days. The Director of Nursing verified the accuracy of the medication error report and the medication administration record, acknowledging the mistake in the resident's medication order record.
Medication Over-Administration Leads to Resident Fall
Penalty
Summary
The facility failed to ensure a resident's medication regimen was free from unnecessary PRN medications, leading to an incident involving over-administration of sleep medication. A resident experienced a fall due to the over-administration of Ambien, which was discovered during a complaint survey. The root cause of the fall was identified as the over-administration of the resident's prescribed sleep medication, Ambien, on a specific date. The facility's investigation revealed that a nurse transcribed a provider order for a one-time dose of Ambien but failed to discontinue the medication after administration. Consequently, another nurse administered both the standing dose and the one-time dose of Ambien, resulting in the resident receiving an excessive amount of the medication. Following the fall incident, a nurse assessed the resident and observed a red bump/bruise on the resident's head. The resident was lethargic when assisted to the bathroom, prompting a medication review. The review confirmed that the resident had been given a higher dose of sleep medication than prescribed. The Director of Nursing confirmed the findings of the investigation and the fall incident report, acknowledging the transcription error and the subsequent over-administration of the medication.
Medication Order Inaccuracy Leads to Over-Administration of Ambien
Penalty
Summary
The facility failed to maintain an accurate medication order history for a resident, which led to the over-administration of the prescribed sleep medication, Ambien. The issue was identified during a complaint survey, where it was found that a nurse transcribed a provider order for a one-time dose of 12.5mg Ambien but did not discontinue the medication after administration. As a result, the resident received both the standing dose of 6.25mg and the one-time dose of 12.5mg on multiple occasions. The medication error was confirmed through a review of the resident's medication administration record (MAR) for September 2022, which showed that the one-time dose was administered on three consecutive days. The Director of Nursing confirmed the accuracy of the medication error report and the MAR, acknowledging the mistake in the resident's medication order record.
Failure to Transmit MDS Data Timely
Penalty
Summary
The facility failed to adhere to the Resident Assessment Instrument (RAI) Manual's transmission requirements for the Minimum Data Set (MDS) data. Specifically, the facility did not electronically transmit the encoded, accurate, and complete MDS data to the Center for Medicare & Medicaid Services (CMS) System within the required timeframe for one resident. The resident, who was admitted with diagnoses of congestive heart failure and pneumonia, was discharged to another facility. Despite the discharge MDS being completed, it was not submitted to the CMS System over 120 days after the discharge. The MDS Coordinator acknowledged that the discharge MDS was completed but not submitted, citing a lack of reports from the electronic medical record (EMR) system to notify her of the oversight. Additionally, there was no auditing system in place to ensure timely submission of MDSs. The Director of Nursing expected the MDS Coordinator to complete and submit the MDS in accordance with the RAI Manual and to verify that submissions were made. The CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual specifies that a discharge assessment must be completed within 14 days after the discharge date and submitted within 14 days after the MDS completion date.
Failure to Implement Medication Change
Penalty
Summary
The facility staff failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically concerning the administration of metformin. A consultant pharmacist conducted a monthly review and recommended reducing the resident's metformin dosage from 500 mg twice daily to 500 mg once daily, as the resident's A1c levels were well within the goal. The attending physician agreed to this recommendation and signed off on the change. However, the order to reduce the dosage was not implemented, and the resident continued to receive the higher dosage of metformin twice daily. The facility's process for handling consultant pharmacist recommendations involved placing the review in a folder for the physician, who would then review and write any new orders. In this case, the order was not updated to reflect the agreed change, resulting in the resident receiving an unnecessary dosage of medication. The Unit Manager confirmed that the order was not written to decrease the metformin dosage, and the resident continued to receive the higher dosage from the date of the physician's agreement until the deficiency was identified.
Medication Errors Result in 5.13% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 5.13 percent. This was due to two medication errors involving two residents. The first error involved a resident with type 2 diabetes mellitus who was prescribed Lantus Solostar insulin. During administration, the LPN did not prime the insulin pen or hold it in the resident's abdomen for the recommended time, contrary to the manufacturer's guidance. The LPN admitted to not being trained in these procedures, and the Director of Nursing confirmed the expectation for staff to follow the manufacturer's instructions. The second error involved a resident with a diagnosis of duodenal ulcer and acute gastritis, who was prescribed sucralfate to be taken four times daily. The medication was not administered at the scheduled time because the RN could not locate the medication card, which was later found to be placed backward in the medication cart. The Director of Nursing acknowledged that the medication was available and should not have been missed.
Medication Administration Errors Due to Inadequate Staff Training
Penalty
Summary
The facility failed to ensure that two staff members had the necessary competencies and skills to prevent medication errors, resulting in two residents receiving incorrect medication doses. Resident 174, who was admitted with multiple diagnoses including bone disorder and arthritis, was mistakenly given 5 mg of oxycodone instead of the prescribed 2.5 mg. This error occurred because Certified Medicine Aide (CMA) 1 pulled the wrong medication card from the cart, confusing Resident 174's medication with that of another resident. CMA1 admitted to the error, stating that she had not received proper education or observation in medication administration until after the incident. Another incident involved Resident 15, who was admitted with type 2 diabetes mellitus and had an order for Lantus Solostar insulin. Licensed Practical Nurse (LPN) 3 administered the insulin without priming the pen or holding it in the abdomen for the required time, as she had not been trained on the correct procedure. The Infection Preventionist confirmed that LPN3 did not attend a skills fair that included insulin pen administration training, and the Director of Nursing was unaware of the lack of training. The facility's documentation revealed that there was no evidence of medication administration education or observation for CMA1 in 2022, and LPN3's training did not cover insulin pen administration. The facility's assessment tool indicated that staff training and competencies were supposed to be verified upon orientation and as needed, but this was not adequately implemented, leading to the medication errors observed.
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What surveyors actually found near you
We read the 355 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Williamsport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Williamsport Health And Rehabilitation Center | 1.2 mi | ★★★★★ | 11 | 1 |
| Creekside Center For Rehabilitation And Nursing | 4.4 mi | ★★★★★ | 34 | 1 |
| Julia Manor Nursing And Rehabilitation Center | 4.6 mi | ★★★★★ | 47 | 0 |
| Hagerstown Healthcare Center | 5.1 mi | ★★★★★ | 28 | 0 |
| Coffman Nursing Home | 5.6 mi | ★★★★★ | 16 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.