Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Williamsport Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident was discharged home without evidence that needed post-discharge services were in place. The record showed the resident required substantial to maximum assist for ADLs and was dependent for bed mobility and transfers, with wounds needing care. The NP documented that home health would be provided, but no services were set up before discharge. Social services sent referrals but did not confirm placement, and the home health agency later said it could not accept the resident without a community PCP. The resident and family reported no home health or therapy had been arranged and that the resident could not transfer or be cared for safely at home.
Facility staff failed to properly document two residents’ discharges. For one resident, there was no nursing discharge note showing a safe and orderly discharge, and the discharge instructions lacked clear documentation of who provided them by phone. For another resident, a 30-day discharge notice was issued for nonpayment, but the reason was not documented in the progress note and the notice was not initially uploaded to the chart.
Incomplete Post-Fall Neurochecks: A resident had post-fall neurochecks documented after falls, but the assessments did not include a full set of VS for each required timeframe. One neurocheck entry was completed while the remaining entries were blank, and staff later stated they transcribed assessments from paper notes but could not provide evidence that full VS were obtained.
A resident with dementia and impaired walking had a fall-risk care plan, but staff did not include the needed level of supervision to prevent falls. The resident was found on the floor near the bed, later found on the floor again, and the family reported being told the resident had fallen from a wheelchair and then from the bed. The unit manager stated there was no rationale for why the supervision level needed to prevent the falls was not included.
Two residents with documented wishes for no CPR received resuscitation after staff failed to follow or locate the correct MOLST forms, resulting in conflicting code status orders and lack of a clear process for verifying advance directives. Staff confusion and inconsistent documentation contributed to the deficiency.
A resident's care plan meeting was conducted in their room with a roommate present, resulting in a breach of privacy when the roommate made comments indicating they were listening. Staff had adopted the practice of holding care plan meetings in residents' rooms since the COVID-19 pandemic and did not consider the lack of privacy on the LTC unit. The issue was confirmed by interviews with social services staff and was brought up by the resident's family at the end of the meeting.
Staff did not ensure a clean and homelike environment on Unit A, as surveyors observed soiled carpets, crumbs, and debris in resident rooms and hallways. The Environmental Director confirmed that housekeeping was responsible for these areas and identified ongoing issues with cleanliness due to poor time management by the assigned staff.
A resident requiring assistance with personal care did not receive appropriate incontinent care over multiple shifts, resulting in saturated briefs and bedding and a strong urine odor. Documentation was missing or indicated care was not provided, and staff failed to notify nursing or provide education when care was refused. The DON confirmed that lack of documentation meant the care was not completed.
Staff failed to maintain accurate and consistent code status information in medical records, resulting in two residents receiving unwanted CPR due to conflicting MOLST forms and physician orders. The facility did not ensure all staff were educated on the correct process, and the QAPI committee did not address or follow up on the identified deficiencies.
Insufficient staffing delayed resident care and morning transfers. Surveyors observed a GNA trying to find help to get a resident out of bed while a mechanical lift was in the room, and later found two residents still in bed eating lunch. Record review showed one resident was supposed to be out of bed for breakfast, while another had no documented preference to remain in bed until after lunch. The facility assessment said 32 GNAs were needed daily, but schedules showed fewer GNAs than required, and staff interviews confirmed it was difficult to bathe and transfer residents needing 2-person assistance.
Grievance Process Did Not Provide Resident Copy or Signature for Resolution: A resident admitted for rehab reported missing clothing, but the grievance was not documented on a form. Interviews with the SSD and Administrator showed the facility’s grievance process allowed verbal or electronic complaints, yet residents were not required to sign for the resolution and did not receive a written copy unless they asked. Review of completed grievance forms and the facility policy showed no place or requirement for resident signature or receipt of the completed grievance.
Lack of Qualified Dietary Service Supervisor: The facility failed to ensure a full-time qualified dietetic service supervisor was overseeing food prep and daily kitchen operations. The kitchen manager reported only ServSafe credentials and said she was still taking the CDM class, while the Regional Dietary Manager stated he was filling in and could not confirm his CDM certification. Additional interviews showed the person responsible for kitchen oversight was not a CDM, the Administrator believed the kitchen manager was a CDM, and the RDs reported they did not oversee the kitchen.
Failure to Maintain Clean and Comfortable Environment: Surveyors repeatedly observed strong urine odors and stained, worn carpeting throughout multiple hallways, floors, and in a resident’s room. A resident and family member voiced concerns that the carpet near the bed was filthy, and facility leadership acknowledged awareness of the odors and carpet condition.
Medication storage was not properly secured or maintained in several areas. Surveyors found an unsecured medication room with unlocked cabinets and an unlocked refrigerator containing medications and supplies, medication refrigerators with ice buildup and missing or out-of-range temperature logs, food stored in a medication refrigerator, and both an unlocked medication cart and an unlocked treatment cart left unattended. The DON confirmed several of these conditions and acknowledged that the carts and medication storage areas should have been locked when not in use.
A resident's representative was wrongfully denied access to medical records after the resident's death, despite having a healthcare POA documented in the advanced directive. The request was denied by a third-party vendor due to missing documentation, which facility staff failed to review and provide, resulting in the representative's rights not being honored.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not provide required annual performance reviews or 12 hours of in-service training for two GNAs, as confirmed by record review and staff interviews. Leadership acknowledged the lack of documentation for these requirements over multiple years.
A resident did not receive several prescribed medications at the correct times, including doses of hydroxyzine, doxycycline, Entresto, and trimethoprim, which were administered either late or too close together. Staff confirmed these deviations from physician orders and professional standards, as documented in medication administration records and through interviews.
Failure to Report Injury of Unknown Origin: A resident with multiple chronic conditions had blood noted in the brief and bleeding from the private area with no visible source identified. The family reported the concern, and the DON acknowledged the cause could not be determined, but no formal report was made to OHCQ, the ombudsman, or law enforcement as required by facility policy.
Failure to Investigate Injury of Unknown Origin: A resident with multiple chronic conditions had unexplained bleeding from the private area, with blood noted in the brief and no visible source identified. The family reported concern that the cause was not fully investigated, and the DON later acknowledged that no formal investigation was initiated or reported to OHCQ, the ombudsman, or law enforcement, despite facility policy requiring an immediate thorough investigation.
MDS Did Not Accurately Reflect Resident Skin Condition: A resident with a history of stroke, incontinence, and dependence for personal care had MDS skin coding that showed no pressure ulcers or other skin problems, despite care plan documentation of an unstageable sacral pressure ulcer, wound care orders, and a wound note describing sacral gluteal dermatosis continuing to heal. Staff confirmed the MDS should have reflected the current skin condition.
A resident reported having hearing aids but said staff did not have time to put them in, and the surveyor observed the resident was not wearing them. Record review found no care plan or Kardex reference to hearing aids, the admission assessment documented the resident as hard of hearing without hearing aids, and the TAR had no place to document hearing aid use. A nurse said the hearing aids were kept locked in the med cart, and the DON confirmed the record did not show that the resident required or was receiving hearing aids.
Missed Ordered Pressure Ulcer Care: Two residents did not receive or have documentation of ordered wound care and pressure-relief interventions. One resident with an unstageable sacral PU, stroke history, aphasia, and incontinence had multiple ordered treatments, including turning, incontinence care, barrier cream, heel floating, and low air loss mattress checks, with no documentation they were completed. Another resident with pressure ulcers, incontinence, and chronic pain had sacral wound dressing changes and other pressure-relief measures missed or not documented, including entries showing the resident was asleep when wound care was due.
Urine Collection Bag Not Secured Below Bladder: A resident with an indwelling Foley catheter and a history of CKD was observed with the urine collection bag laying on the bed instead of secured below the bladder. An LPN stated aides had forgotten to secure it after continence care, and both the LPN and DON acknowledged the bag should be positioned below the resident’s bladder.
Failure to properly monitor a resident receiving G-tube nutrition was identified. The resident had weight loss documented, but there was no order for weekly weights despite facility policy for weekly weights on admission and thereafter for short-term stay residents. Although the MAR included a section for residual checks before feedings, no residual amounts were documented, and the DON and RD confirmed that the actual residual volume should have been recorded.
A resident was observed receiving oxygen via nasal cannula at 3 LPM, but the medical record showed an order for 2 LPM. An LPN confirmed she was unsure of the resident's oxygen order, then verified the ordered rate and stated she would adjust it right away. The DON later acknowledged the discrepancy.
A resident newly admitted to the facility was receiving PRN tramadol for pain but reported that the medication was not helping much. The eMAR showed the medication was given 5 times, yet the nurse documentation did not show that NPI were attempted or administered before each dose and did not identify the pain location. The DON later confirmed the resident had pelvic pain related to a pelvic fracture, and the pain care plan did not specify the pain’s cause.
The facility failed to accurately document controlled substance counts in the A-wing and C-wing narcotics logs. Surveyors found missing signatures, incomplete count verification fields, blank entries, and improper use of NA or dashes instead of required yes/no responses. Nurses and the DON confirmed that two licensed staff are required to complete and verify the counts, and the facility policy required a physical inventory of controlled substances at shift change or key transfer.
Failure to respond to a pharmacist recommendation was identified for a resident receiving Risperidone. The MRR noted the order lacked an allowable diagnosis to support use, but the PMHNP signed the report without documenting a response, and the order still did not reflect the appropriate diagnosis when reviewed by the DON.
Failure to provide routine dental services to a resident with intact cognition. A resident with broken teeth reported not seeing a dentist since admission, and the most recent assessment documented an obvious or likely cavity or broken natural teeth. The DON later confirmed there were no dental notes and that the resident had not seen a dentist through Healthdrive, the facility’s dental provider.
A facility failed to ensure that residents received the beverages listed on their meal tickets and documented as preferences. During lunch tray observations, milk was missing from the trays of four residents even though it was listed on the tickets, and multiple staff confirmed the omission. Record review showed those residents had milk documented as a preferred breakfast beverage, and the Dietary Mgr stated that known beverage preferences were expected to be honored.
A resident’s air mattress pump was found hanging on the footboard with frayed electrical wires on the floor and no indicator lights on. The unit nurse was unaware the pump was not working until informed by the surveyor, and the A wing unit manager stated she did not know it was broken and that nurses did not document equipment checks anywhere. The DON acknowledged the equipment was found in disrepair.
Call bells were found out of reach for several residents and not working for two others. Surveyors observed residents in bed or eating breakfast with call devices placed in drawers or on the floor, and staff acknowledged several were out of place. Two residents reported call bells that had not functioned for hours or days, and one resident with cognitive impairment, limited mobility, and a history of falls was also found with the call device on the floor and inaccessible.
Surveyors found that required daily nurse staffing information was not consistently posted, and records of these postings were not retained for the required period. The DON confirmed that postings were missing and that historical records were unavailable, affecting all nursing units.
The facility did not ensure that all grievances were investigated and responded to promptly. Two residents reported repeated concerns about long call light response times and staffing, but their complaints were not consistently documented, investigated, or addressed according to policy. Audit reports confirmed extended wait times, and staff interviews revealed lapses in grievance handling and communication.
A resident's personal funds were misappropriated when an agency LPN took possession of the resident's credit card and driver’s license while the resident was temporarily transferred out of the facility. The LPN admitted to making unauthorized charges, including the purchase of a $100 Amazon gift card, using the resident’s credit card.
A resident developed a blister on the right foot after nursing staff applied a warm compress and failed to monitor the skin condition afterward. The compress was secured with an ace bandage, and no immediate discomfort was noted, but lack of follow-up led to the injury. The DON confirmed that staff did not monitor the resident as required.
Insufficient nursing staff resulted in two residents experiencing prolonged call light response times, with waits ranging from 30 minutes to several hours for assistance with incontinence care, toileting, and meal-related needs. Staff interviews and call bell audits confirmed that low staffing levels contributed to these delays, and the DON was unable to justify the adequacy of staffing when presented with evidence of the extended response times.
Facility staff administered insulin to two non-diabetic residents, resulting in significant medication errors. One resident with a history of kidney/pancreas transplant and hypoglycemia monitoring was injected with insulin and required frequent glucose checks and glucose tablets. Another resident with multiple chronic conditions but no diabetes diagnosis also received insulin after being confused with another patient. The LPN admitted to mixing up residents, and the facility did not conduct an internal investigation or report the incident to the appropriate health authority.
Inappropriate discharge without arranged post-discharge services
Penalty
Summary
The facility discharged a resident home without evidence that the resident was prepared for a safe discharge or that needed post-discharge services were in place. The resident's record showed no cognitive impairment on an MDS with an ARD of 4/8/26, and a NOMNC signed on 4/20/26 documented the last covered day as 4/22/26. Social Services documented that the resident appealed the coverage decision, but the appeal was upheld. A discharge MDS with an ARD of 4/23/26 showed the resident required substantial to maximum assistance for some ADLs and was dependent on staff for mobility in and out of bed and for transfers between surfaces. On 4/23/26, the NP documented that the resident needed moderate to maximal assistance, had wounds requiring wound care, and was going home with home health services, but the record contained no evidence that home health had been arranged before discharge. The NP also noted a mechanical lift had been offered, but the family declined because of limited space in the home, and that the resident needed to establish a primary care doctor in the community. The resident and family later stated that no home health or therapy services had been set up before discharge and that the resident could not move from one surface to another and was difficult to bathe and care for. Social Services stated she faxed referrals to two home health agencies but did not follow up to ensure services were established, and the home health agency later reported it could not provide services without a community primary care doctor. The Nursing Home Administrator stated the discharge was resident initiated, but there was no evidence in the record or interviews that this was the case.
Failure to Document Resident Discharges and Discharge Notices
Penalty
Summary
Facility staff failed to document a resident’s discharge as required for Resident #3. The medical record showed a discharge summary written by the NP stating the resident was discharged, but there was no nursing discharge note describing how staff provided a safe and orderly discharge. The discharge instructions were completed in the assessment tab by the ADON, and the uploaded discharge instructions contained a handwritten note stating they were given via telephone, but there was no date, time, or signature identifying who provided them over the phone. The ADON stated that on the day of discharge staff were to print the discharge instructions, review them with the resident and the person taking the resident home, and have them sign the instructions, and that the nurse should write a progress note about the discharge. Facility staff also failed to properly document a 30-day discharge notice for Resident #4. A progress note written by Social Services Staff #8 stated she was asked to provide a 30-day discharge notice to the resident, but she did not document the reason for the discharge in the note. The progress notes did not show the reason the resident was issued the notice, and the uploaded documents did not initially contain a copy of the 30-day discharge notice. Social Services Staff #8 later stated the resident was issued the notice due to failure to pay the facility for services, and the Regional Social Worker stated the reason should have been on the 30-day discharge notice that was supposed to be uploaded into the medical record.
Incomplete Post-Fall Neurochecks
Penalty
Summary
Facility staff failed to provide quality of care related to post-fall neurological assessments for Resident #1. The record review showed that after a fall with an unclear time, a post-fall assessment was completed and a neurocheck was documented for the required timeframes, but the assessment did not include a full set of vital signs for each neurocheck. A separate post-fall assessment documented another fall on 11/25/25 at 5:20 AM, and the neurocheck record showed only one assessment entered around 8:30 AM by LPN #6, with the remaining assessments left blank. The vital signs tab also showed that this was the only vital sign entry for that date. During interview, LPN #2 stated that she writes neurochecks on paper at the time of assessment and later transcribes them into the computer, and she thought she may have forgotten to change the date and time for all vital signs because they auto-populate to the last set taken. She was unable to provide evidence that a full set of vital signs had been obtained. LPN #6 stated she could not recall what happened that day and said she normally writes neurochecks on a cheat sheet and enters them later, but she did not retain a copy of the cheat sheet. The unit manager stated she would review post-fall forms the next day she was on duty, but could not provide a rationale for why this resident's falls had not been reviewed. The DON was informed of the concerns.
Failure to Provide Adequate Supervision for a Resident at Risk for Falls
Penalty
Summary
The facility failed to ensure that a resident at risk for falls was free from accident hazards and received adequate supervision to prevent accidents. Resident #1 had a fall-risk care plan initiated on 11/17/25 with interventions to keep commonly used items nearby and remind the resident to use the call light. The attending physician documented on 11/18/26 that the resident had dementia and an abnormality with walking. A post-fall assessment completed on 11/21/25 documented that the resident was found on the floor near the bed. The care plan was not updated to reflect an actual fall until 11/24/25, four days after the fall, and the goal remained unchanged; an intervention was added to offer the resident to go back to bed after visitors left. The assessment tab later showed the resident was found on the floor again on 11/25/25, and the care plan was updated to add keeping the bed in the lowest position. The resident's family member stated they were told the resident had fallen out of the wheelchair and then out of the bed, and believed staff had not checked on the resident enough to prevent the falls. The unit manager stated she had no rationale for why the level of supervision needed to prevent the resident from falling was not included.
Failure to Honor Residents' Advance Directives for CPR Due to Inadequate MOLST Management
Penalty
Summary
The facility failed to have a process in place to ensure that residents' choices regarding cardiopulmonary resuscitation (CPR), as documented in their Maryland Orders for Life-Sustaining Treatment (MOLST) forms, were honored. This deficiency was identified through record review and staff interviews, which revealed that staff were unclear about where to locate the active MOLST forms in the electronic medical record. Multiple staff members reported different methods for determining code status, including checking the information bar, reviewing uploaded documents, or referencing daily assignment sheets. However, there was no standardized procedure, and it was noted that retrieving the correct information could be time-consuming. For one resident, two active MOLST forms were found in the medical record: one indicating full code status and another, more recent, indicating no CPR. The older form was not voided, and conflicting physician orders were present in the system. When the resident was found unresponsive, CPR was initiated by staff, and it was only after EMS arrived and reviewed the paperwork that the resident's wish for no CPR was discovered. Staff failed to document the time CPR was started, and interviews revealed a lack of recall about the incident and confusion regarding the correct code status at the time of the event. An audit following the incident identified other residents with multiple active MOLST forms and conflicting code status orders. A similar incident occurred with another resident who had an active MOLST indicating no CPR, but this document was not uploaded into the record until after a conflicting full code order had been entered and remained active. When the resident coded, CPR was initiated despite the resident's documented wishes. Staff interviews and review of statements failed to clarify where the nurse checked for code status before starting CPR, and it was confirmed that two active MOLST forms were present in the record at the time. These failures led to the declaration of Immediate Jeopardy due to the facility's inability to ensure residents' advance directives were followed.
Removal Plan
- The facility completed audit of all MOLST forms and code status orders to ensure they matched.
- Any discrepancies identified were corrected upon discovery.
- The audit was completed by the Assistant Director of Nursing.
- All clinical nursing staff in the facility, including agency staff, were educated on ensuring that when a code event occurs, they are to look in Point Click Care under documents and filter for category MOLST for the active MOLST.
- Any staff not available will be educated prior to beginning their next scheduled shift to include active agency staff.
Failure to Ensure Privacy During Care Plan Meetings
Penalty
Summary
Facility staff failed to ensure the privacy of residents' personal and medical information by conducting care plan meetings in residents' rooms while roommates were present. In one instance, a care plan meeting was held in a resident's room on the LTC unit with the roommate present, and the roommate made a comment indicating they were listening to the discussion. The staff had pulled the curtain for privacy, but this did not prevent the roommate from overhearing the meeting. The practice of holding care plan meetings in residents' rooms had been adopted since the COVID-19 pandemic, and staff did not consider the lack of privacy when the resident was placed on the LTC unit. Interviews with the Director of Social Services and Social Services staff confirmed that care plan meetings were routinely held in residents' rooms, and that the privacy of the meetings was not always ensured, especially when a roommate was present. The Director of Social Services acknowledged that the room layout did not provide sufficient privacy for such meetings, particularly on the LTC unit. The issue was brought to the attention of staff by the resident's family, but only at the end of the meeting.
Failure to Maintain Clean and Homelike Environment on Unit A
Penalty
Summary
Facility staff failed to maintain a clean and homelike environment for residents on Unit A, as evidenced by multiple observations of visibly soiled and debris-laden floors in resident rooms and hallways. On two separate occasions, surveyors noted carpeted floors near doorways that were visibly soiled, as well as crumbs and debris under beds and in hallways. Additional debris, such as a cup lid, was found near the door to the room with the ice chest. The Environmental Director confirmed that housekeeping staff were responsible for keeping these areas clean and acknowledged ongoing issues with cleanliness on Unit A, attributing the problem to a lack of time management skills by the assigned housekeeper.
Failure to Provide and Document Incontinent Care
Penalty
Summary
The facility failed to provide appropriate incontinent care for a resident who required assistance with personal care. On two consecutive days, a complaint was received that the resident had not been changed, resulting in a strong odor of urine and saturated briefs and bedding. Review of assignment sheets showed limited staffing during the relevant shifts, and documentation for incontinent care was either missing or indicated that care was not provided. Specifically, there was no record of incontinence care being performed on several shifts, and on one occasion, the resident was documented as refusing care without any evidence that the nurse was notified or that education was provided to the resident. Medical record review confirmed that the resident needed thorough skin care for each incontinent episode, as recommended by a nurse practitioner treating the resident's wounds. The Director of Nursing, in the presence of the Nursing Home Administrator, acknowledged concerns regarding the lack of documentation and agreed that if staff did not sign off on the task, it was considered not done. The findings were based on both documentation review and interviews, confirming that incontinent care was not consistently provided or properly documented for the resident in question.
Failure to Address Conflicting Code Status Orders Resulting in Unwanted CPR
Penalty
Summary
The facility failed to implement corrective action after identifying that staff maintained inaccurate and inconsistent code status information in residents' medical records. This deficiency resulted in residents receiving unwanted Cardiopulmonary Resuscitation (CPR). In one instance, a resident's medical record contained two active Maryland Orders for Life Sustaining Treatment (MOLST) forms with conflicting code statuses—one indicating full code and another indicating no CPR. When the resident was found unresponsive, CPR was initiated despite the resident's documented wish not to receive it. The medical record also lacked documentation of the time CPR was started. A subsequent audit revealed additional residents with more than one active MOLST and conflicting code status physician orders. The process for updating and voiding MOLST forms and corresponding orders was not consistently followed, and not all nursing staff received education on the correct procedures. Despite the identification of these issues, the facility's Quality Assurance Performance Improvement (QAPI) committee meeting minutes over an eleven-month period did not document discussion or follow-up on the performance improvement plan (PIP) created to address the problem. In another case, a resident with an active MOLST indicating no CPR had conflicting physician orders in the medical record, including an order for full code that remained active until the resident coded. The resident received unwanted CPR for twelve minutes. The DON did not fully investigate the incident to determine the cause or ensure corrective action was taken. The QAPI committee failed to review or address this system breakdown in their meetings, and there was no evidence of actions taken to prevent recurrence.
Insufficient staffing delayed resident care and morning transfers
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet resident needs and to have a licensed nurse in charge on each shift. Surveyors observed GNA #2 trying to find help to get a resident out of bed while a mechanical lift was in the room, and later observed two residents still in bed eating lunch. One of those residents was later assisted out of bed by GNA #2, who stated that it was the first time she had time to get that resident up. Record review showed one resident had no documented preference to get out of bed after lunch, while another resident’s care plan directed that the resident be out of bed for breakfast. The facility assessment, signed by the NHA and reviewed by the quality assurance committee, stated that 32 GNAs were needed each day, but staffing schedules for multiple dates showed fewer GNAs than required. On one observed day, the C-wing downstairs unit had 16 residents with only 1 GNA assigned there and 1 nurse covering both upstairs and downstairs C-wing units; the upstairs GNA was required to stay on that unit unless relieved. The downstairs unit included residents who required two staff for bed mobility and transfers, residents dependent on bathing, dressing, and toileting, and residents needing feeding or cueing. Staff interviews confirmed that it was difficult to bathe and get residents out of bed in the morning, especially residents needing two-person assistance, and the DON and NHA acknowledged that staffing levels were not enough to allow residents to be bathed and gotten out of bed in a timely manner.
Grievance Process Did Not Provide Resident Copy or Signature for Resolution
Penalty
Summary
The facility failed to follow its grievance procedure for a resident who reported that one of his or her long pants was missing. On 7/15/2025, the resident, who had been admitted for rehabilitation, told staff that the missing pants had already been reported to a facility staff member. During the survey, the Director of Social Services and Discharge Planning confirmed that there was no grievance form on file for the missing pants complaint. Interviews with the Director of Social Work & Discharge Planning and the Administrator showed that the facility’s grievance process allowed residents or family members to report concerns verbally or electronically, with staff documenting the grievance online and routing it for resolution. However, the process did not require the resident to sign that the grievance had been resolved, and residents did not receive a written copy unless they specifically requested one. Review of 8 completed grievance forms from 4/7/25 to 7/3/25 showed no space for residents to sign that they reviewed or received a copy of the completed grievance form, and the facility policy titled Service Concerns/Grievances did not include a requirement for residents to sign or receive a copy.
Lack of Qualified Dietary Service Supervisor
Penalty
Summary
The facility failed to ensure a full-time qualified dietetic service supervisor was in place for oversight of food preparation and daily kitchen operations. During an observation of the kitchen, the kitchen manager stated that her highest credential was ServSafe and that she was still taking the Certified Dietary Manager (CDM) class. She also reported receiving consultation from the Regional Dietary Manager. When interviewed, the Regional Dietary Manager stated he was filling in for the regular dietary manager and was not sure whether he had reviewed his CDM certification; no CDM certification was provided before the end of the survey. Further interviews showed conflicting information about who was responsible for kitchen oversight and whether that person was qualified. One Regional Dietary Manager stated she was responsible for oversight of the kitchen but was not a CDM. The Administrator stated she wanted to take responsibility for not having a CDM and believed the current kitchen manager was a CDM. The Registered Dietitian reported providing services on site and remotely but did not oversee the kitchen, and another Registered Dietitian reported working on site one day a week with remote hours and being certified as a CMD, but stated he had not had any oversight responsibilities for the facility kitchen. The concerns were shared with the DON, and no additional information was provided before the end of the survey.
Failure to Maintain Clean and Comfortable Environment
Penalty
Summary
The facility failed to maintain a clean and comfortable homelike environment, as shown by repeated observations of strong urine odors and stained carpeting throughout multiple areas of the building over eight days of environmental observations. Surveyors noted a strong urine smell in the C-wing on 7/15/2025, along with stains on the carpeting throughout that wing. Resident #33 and the resident’s family member expressed concerns about the facility’s cleanliness, and the family member pointed to the carpet near the resident’s bed, stating that it was filthy; the surveyor observed heavy staining in that area. The urine odor in the C-wing continued to be observed on multiple subsequent dates, including a stale, wet smell, and surveyors also noted intermittent dirt-stained carpeting on the first, second, and third floors, as well as in the elevator. Resident #33’s room continued to have heavily stained carpet on both sides of the bed, and the C-wing hallway carpeting remained soiled and worn. On 7/24/2025, the surveyor observed strong urine odors in hallways A and C and continued staining from the administrative offices to the elevator on the main floor, outside the elevator on the second floor, and in the C hallway. The Regional Director of Clinical Operations confirmed awareness of the urine odors and carpet condition, and the Maintenance Director confirmed there were areas of the facility with stained carpet.
Medication storage areas, refrigerators, carts, and temperature monitoring were not secured or maintained properly
Penalty
Summary
The facility failed to ensure proper medication storage in multiple areas, including unsecured medication storage spaces, medication carts, treatment carts, and medication refrigerators. During observation of the C-Wing medication storage room, the door could not be locked, the medication refrigerator was unsecured, and the cabinets were also unsecured. Inside the room were multiple bottles of over-the-counter medications, lancets, syringes, alcohol pads, medical grade disinfectant wipes, wound care cleaner, and a plastic container on the floor containing resident prescription medications in blister packs. The facility also failed to maintain medication refrigerator temperatures and conditions in accordance with policy and manufacturer instructions. In the C-Wing and A-Wing medication rooms, surveyors observed significant ice buildup in the refrigerators/freezers. Temperature logs showed missing documentation on multiple dates, no logs provided for some months, and recorded temperatures below the required range, including temperatures near freezing. The DON confirmed that the refrigerators were not being properly monitored, that corrective actions were not documented when temperatures dropped below the required range, and that the units had not been defrosted according to facility policy. In another medication storage area, the medication refrigerator contained food items, specifically raspberry sherbet and chocolate ice cream, stored with medications. The DON acknowledged that food was not to be stored with medications and discarded the items. Surveyors also observed an unlocked medication cart on the Canal Side Terrace B unit while residents were wandering nearby, and an unlocked treatment cart on A Wing. Staff confirmed that the carts should have been locked when unattended, and the DON confirmed that medication carts and treatment carts were expected to be locked when not in use.
Failure to Provide Resident Records to Authorized Representative
Penalty
Summary
The facility failed to honor a resident representative's right to access the resident's personal and medical records following the resident's death. The representative completed a medical records request form at the facility, but later received a phone call from staff stating the request was denied without further explanation. The medical records coordinator reported that requests are sent to a third-party company, Rytes, for determination. In this case, Rytes denied the request, citing a lack of supporting documentation to prove the representative's authority. However, the resident's medical record contained an advanced directive appointing the representative as the healthcare power of attorney, which was not reviewed or provided to Rytes by the facility staff. The medical records coordinator admitted to not reviewing resident records and relying solely on Rytes to determine eligibility for record release. Both the coordinator and Rytes had access to the resident's medical record, which included the necessary advanced directive. The failure to review the resident's file and provide the required documentation resulted in the wrongful denial of the records request. The deficiency was confirmed through interviews and record reviews, which showed that the facility did not follow proper procedures to ensure the representative's right to access the records was honored.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Annual Performance Reviews and In-Service Training for GNAs
Penalty
Summary
The facility failed to ensure that Geriatric Nursing Assistants (GNAs) received required annual performance reviews and at least 12 hours per year of in-service training, as identified through record review and staff interviews. Specifically, two GNAs did not have documentation of annual performance appraisals or the mandated in-service education for the years 2022-2025. The Director of Nursing (DON) and the Staff Development Coordinator (SDC) confirmed that tracking of training compliance was their responsibility, and acknowledged the absence of required documentation in the employee files. These findings were based on a review of six employee training records and interviews with facility leadership.
Failure to Administer Medications as Ordered by Physician
Penalty
Summary
A deficiency was identified when a resident did not receive medications as ordered by the physician. Document review and staff interviews revealed that multiple medications, including hydroxyzine HCL, doxycycline monohydrate, Entresto, and trimethoprim, were not administered at the prescribed times. For example, hydroxyzine was given more than two hours late for one dose and less than two hours apart for another, contrary to the physician's orders. Other medications, such as doxycycline and Entresto, were also administered several hours later than scheduled, with some doses given late at night instead of in the morning as ordered. Staff interviews confirmed that these administration times did not meet professional standards, with the Assistant Director of Nursing acknowledging that medications given more than one hour before or after the scheduled time constituted a medication error. The Director of Nursing also confirmed that the medications listed were not administered as ordered. These findings were based on a review of medication administration records and staff interpretations, and were substantiated by a complaint from a county agency regarding the resident not receiving medications on time.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for Resident #33. Resident #33 had a history of hypertensive heart disease, bladder and fecal incontinence, pressure ulcers, chronic pain, and required assistance with personal care. A change in condition note documented that staff were called to the room for blood noted in the resident’s brief, and observation showed blood appearing to come from inside the resident’s private area with no visible source in the surrounding area and a clot noted at the entrance to the private area. The resident’s family member later reported that the resident had called upset and stated that the private area was bleeding, and the family said they had raised the concern with the facility. The Director of Nursing stated she investigated the incident and believed a small amount of blood had been found in the undergarment in June 2025, but the cause could not be determined. She confirmed that no formal report was made to OHCQ, the ombudsman, or local law enforcement, despite the facility policy requiring immediate reporting of alleged injuries of unknown origin to the State Agency without delay and no later than two hours after the allegation is made.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for one resident who had a history of hypertensive heart disease, bladder and fecal incontinence, pressure ulcers, chronic pain, and required assistance with personal care. The incident involved unexplained bleeding from the resident’s private area, which was first noted when blood was found in the resident’s undergarment and later documented as appearing to come from inside the private area with no visible source in the surrounding area and a clot at the entrance to the private area. The resident’s family member reported that the resident was upset and stated that the private area was bleeding, and the family expressed concern that the cause had not been fully investigated. The family member stated the facility checked the resident’s fingernails to see if scratching caused the injury, but no further steps were taken to determine the cause. The DON stated she was familiar with the incident and said she had investigated it, but later acknowledged she had not documented conversations with the resident or family about the event. The DON also confirmed that the incident was not reported or formally investigated as an injury of unknown origin to OHCQ, the ombudsman, or local law enforcement. Although the facility policy required the Administrator or DON to immediately initiate a thorough internal investigation, including collecting evidence, interviewing the alleged victim and witnesses, and involving appropriate authorities as needed, the DON acknowledged that a formal investigation had not been launched for the unexplained bleeding incident.
MDS Did Not Accurately Reflect Resident Skin Condition
Penalty
Summary
The facility failed to accurately reflect a resident’s skin assessment on the MDS. Resident #11 was legally blind, had a history of cerebral infarction, was incontinent of bowel and bladder, and required assistance with personal care. The resident’s current MDS dated [DATE] coded Section M0300 as zero for all pressure ulcers and Section M1040 as none of the above for other ulcers, wounds, or skin problems. However, the previous MDS dated [DATE] had coded one Stage 3 pressure ulcer in Section M0300, showing a prior pressure ulcer history that was not reflected on the current assessment. Record review also showed the resident’s care plan documented an unstageable pressure ulcer to the sacrum and risk for worsening wounds or additional wounds related to inability to turn and reposition independently and moisture-associated skin damage. A wound care order directed cleansing the sacrum and applying calcium alginate with a silicone-bordered superabsorbent dressing every other day, and a wound care progress note stated that sacral gluteal dermatosis continued to progress toward healing. During interview, the RAC confirmed that MDS Section M should have reflected the resident’s current skin condition, and the Regional Director of Reimbursement acknowledged that Section M1040 of the MDS dated [DATE] should have reflected the presence of sacral gluteal dermatosis as a current skin problem.
Failure to Document and Provide Hearing Aid Use
Penalty
Summary
The facility failed to ensure that Resident #13 received proper treatment and assistive devices to maintain hearing abilities. During interview, the resident stated having hearing aids but reported that staff did not have time to put them in, and the surveyor observed that the resident was not wearing hearing aids. A nurse later reported that the resident sometimes wears hearing aids and that the hearing aids were kept locked in the medication cart, where two hearing aids were observed. Record review showed the care plan did not reference hearing aids, and the admission assessment documented that the resident was hard of hearing and did not have hearing aids. The Treatment Administration Record had no space for nurses to document hearing aid use, and the Kardex also contained no information about hearing aids. The DON stated that hearing aid information should be available to GNAs in the Kardex, but the resident’s record did not show any documentation indicating that hearing aids were required or being received.
Missed Ordered Pressure Ulcer Care
Penalty
Summary
The facility failed to provide physician-ordered pressure ulcer care for two residents. One resident was legally blind, had a history of stroke, urinary incontinence, aphasia, skin disorders, and required assistance with all personal care. The resident had an unstageable sacral pressure ulcer and was identified as being at risk for wound deterioration and additional wounds due to inability to turn and reposition independently and moisture-associated skin damage. The treatment orders included alternating low air loss mattress settings checks, barrier cream after toileting, turning and repositioning every 2 hours, toileting/incontinence care every 2 hours, heel floating, and use of a wedge cushion with side-to-side positioning, but none of these interventions were documented as completed on the evening shift of 7/7/25. The DON reviewed the missing documentation and confirmed there was no evidence the treatments were completed. A second resident had hypertensive heart disease, bladder and fecal incontinence, pressure ulcers, chronic pain, and required assistance with personal care. The resident’s sacral wound order required cleansing, packing with Dakin’s moistened gauze, and covering with a silicone bordered superabsorbent dressing every evening shift, but this was not documented as completed before the order was discontinued. A new sacral wound order later required hydrogel gauze and a silicone bordered dressing every evening shift, yet the treatment record showed entries marked with a 7, indicating the resident was sleeping and the wound care was not performed on the evening shifts of 7/13/25 and 7/14/25. Additional ordered pressure ulcer interventions, including wedge cushion use, turning and repositioning every 2 hours, keeping the head of bed flat except during meals or if short of breath, limiting time out of bed to 2 hours, use of a low air loss mattress, pillow boots, and a pillow between the lower legs, were also not documented as completed on 7/7/25. The DON stated wound care should have been completed once the resident woke up and confirmed blanks in the record typically meant the treatment was not completed or not documented.
Urine Collection Bag Not Secured Below Bladder
Penalty
Summary
Failure to provide appropriate catheter care was identified for Resident #73, who was admitted in early 2023 with diagnoses including chronic kidney disease and had an indwelling Foley catheter. During the initial survey observation on 7/15/25, the resident was in bed in the lowest position, and a tube was seen sticking out from under the blanket with amber-colored fluid in it. When the LPN assigned to the resident was interviewed in the room, the urine collection bag was found laying on the resident’s bed rather than secured below the level of the bladder. The LPN stated that the aides must have forgotten to secure the bag after continence care and acknowledged that the bag needed to be positioned below the resident’s bladder to promote proper urine flow and prevent backflow. A later review of the resident’s care plan showed an intervention to position the catheter bag and tubing below the level of the bladder. The DON was also interviewed and confirmed that the urine collection bag should be secured below the level of the resident.
Failure to Monitor G-Tube Feeding and Document Residuals
Penalty
Summary
Proper monitoring of a resident receiving nutrition through a gastrostomy tube was not provided. Resident #6 was admitted for rehabilitation and received nutrition via a G-tube. A review of the resident’s weight records showed a weight of 180 lbs on 6/6/25 and 177 lbs on 7/1/25. On 7/21/25, a review of medical orders did not reveal an order for weights, although a separate order was found directing staff to check residual prior to feeding every shift, hold the feeding for 1 hour if residual was greater than 120 mL, and call the MD if the residual remained over 120 mL. The facility’s MAR had a section for documenting residual volume prior to each feeding, but no residual amounts were documented. The DON stated that the facility’s weight policy requires weights on admission and weekly thereafter unless otherwise ordered, and that residents receiving nutrition through a gastrostomy tube typically have weight orders entered by the RD. The RD stated that she works onsite two days per week and does not enter weight orders for residents receiving nutrition via G-tube, and she confirmed that Resident #6, as a short-term stay resident, should have had weekly weights and that the actual volume of residuals should be documented. The DON later confirmed that Resident #6 was not getting weekly weights and that there were no orders for how often the resident should be weighed, and also confirmed that residual volume documentation should include the actual measured amount.
Oxygen Therapy Not Provided Per Physician Order
Penalty
Summary
The facility failed to ensure oxygen therapy was provided according to the physician's order for Resident #5. During observation, the resident was in bed receiving oxygen via nasal cannula at 3 liters per minute, while the medical record later showed an order for oxygen at 2 liters per minute via nasal cannula. The assigned LPN confirmed the resident was receiving oxygen at 3 liters per minute, stated she was not sure what the resident's oxygen orders were, and then reviewed the orders and confirmed the prescribed rate was 2 liters per minute. The DON later acknowledged the discrepancy and stated the LPN had already discussed it with her.
Pain Management Documentation Was Incomplete for a Resident Receiving PRN Tramadol
Penalty
Summary
Failure to provide safe, appropriate pain management was identified for one resident who was newly admitted to the facility and was receiving tramadol PRN for pain. During an interview, the resident reported taking pain medication but stated it was not helping that much. The medical record showed an order for tramadol every 8 hours as needed for pain, and the July 2025 eMAR showed the medication was administered 5 times. Review of the medication administration documentation found no order or documentation showing that non-pharmacological interventions were attempted or administered before the tramadol was given on those 5 occasions. The nurse documentation also did not identify the location of the resident’s pain. The DON later confirmed that the resident had pelvic pain related to a pelvic fracture, but the progress notes for the PRN tramadol administrations did not document pain location, and the pain care plan did not specify what the pain was related to.
Incomplete Controlled Substance Count Documentation
Penalty
Summary
The facility failed to ensure accurate documentation of controlled substances in the narcotics daily count logs for both the A-wing and C-wing narcotics record books. During review of the C-wing log, the surveyor found multiple entries where the narcotics count was not signed, the count was not confirmed as correct, or only one staff member signed instead of the required two signatures. Several required fields were also left blank, including Narcotic Kit Sealed, Narcotic Kit Seal Number Verified, and Status of Count Exact. Nurse #15 confirmed these findings. A similar pattern was identified in the A-wing narcotics log, where entries included single-signature counts, missing times, blank verification fields, use of NA in response to yes/no questions, and dashes in place of required responses. Nurse #28 confirmed the omissions. The RN Charge Nurse and DON both acknowledged that two staff members are required to complete narcotic counts and that the documentation fields should be completed as yes/no responses rather than left blank or marked NA when applicable. The facility policy reviewed by the surveyor stated that controlled substances are to be physically inventoried by two licensed personnel at each shift change or when keys are transferred, and that the emergency supply seal must be verified as unbroken.
Failure to Respond to Pharmacist Recommendation for Risperidone Order
Penalty
Summary
The facility failed to ensure that the provider responded to a consulting pharmacist’s recommendation during the monthly medication regimen review for Resident #21. The pharmacist’s 6/30/25 MRR stated that the resident’s Risperidone order lacked an allowable diagnosis to support its use and listed several diagnoses or conditions for the provider to consider adding to the order. The report was signed by the Psychiatric-Mental Health Nurse Practitioner on 7/7/25, but the signature did not indicate any response to the recommendation. Review of the resident’s medical order on 7/17/25 showed that the Risperidone order had last been revised on 7/29/24 and still did not include the appropriate diagnosis to support its use. The DON acknowledged that the provider had signed the pharmacist report without documenting a response and that the order had not been updated to reflect the appropriate diagnosis at the time of review.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide routine dental services to a Medicaid-funded resident with intact cognition. Resident #21, admitted in mid-2020, was observed on interview to have broken teeth and reported not having seen a dentist since being in the facility. The most recent comprehensive assessment, dated 5/1/25, documented that the resident had an obvious or likely cavity or broken natural teeth. When the DON reviewed the record, she found no dental notes and confirmed that the resident had not seen a dentist through Healthdrive, the group the facility used for dental services for residents since the change of ownership in October 2024.
Missing Preferred Beverages on Meal Trays
Penalty
Summary
The facility failed to implement an effective process to ensure that residents received their preferred beverages and the drinks listed on their meal tickets. During lunch tray observations on the terrace unit, milk was listed on the meal tickets for Resident #108, Resident #17, Resident #90, and Resident #91, but milk was not present on any of the four trays. Staff members including a GNA, the Admissions Director, and the Social Service and discharge planning Director each confirmed that the milk was missing from the trays. During interview, the Kitchen Manager stated that the facility had milk available for residents that day and confirmed that residents should receive the items listed on the meal ticket. Record review later showed that the four residents had documented breakfast beverage preferences for milk on their preference sheets. The Regional Dietary Manager stated that it was her expectation that residents' known beverage preferences be honored, and that dietary preferences were documented by the Kitchen Manager on admission, readmission, and quarterly reviews.
Nonfunctioning Air Mattress Pump
Penalty
Summary
Resident #94’s room was observed with an air mattress pump machine hanging on the footboard, with electrical wires lying on the floor, frayed wire ends, and no indicator lights on the unit. The resident was in bed at the time of the observation. The unit nurse was unaware that the air mattress pump was not functioning until informed by the surveyor and stated she would call maintenance. During interview, the A wing unit manager said she was unaware the resident’s air mattress pump was broken and stated that resident care equipment should be checked each shift, but also said nurses did not document those checks anywhere. The DON later reviewed the finding and acknowledged that the resident’s care equipment had been found in disrepair.
Call Bells Not Accessible or Functioning
Penalty
Summary
The facility failed to ensure residents had access to call bells and failed to ensure that call bells were maintained in working condition. During the annual survey screening, several residents were observed with call bells out of reach: one resident was eating breakfast with the call bell placed in a drawer, another resident was sleeping with the call bell on the floor, a third resident had the call bell shut inside a bedside drawer, and another resident was lying in bed with the call bell on the floor. A Unit Manager and nursing assistants acknowledged that the call bells were out of place and moved some of them within reach when the surveyor pointed them out. Two residents were also found with call bells that were present but not functioning. One resident reported that the call bell had not worked since the previous evening and demonstrated that pressing it did not trigger an alert; a nursing assistant confirmed it had not been working and said maintenance was supposed to replace it. Another resident reported the call bell had not worked for several days, stated staff had been informed, and said staff had tested it multiple times without success. A review of another resident's record showed cognitive impairment, limited mobility, and a history of falls; that resident was observed in bed with breakfast nearly finished while the call device remained on the floor and inaccessible, and it was still on the floor later that day until an LPN moved it onto the bed.
Failure to Post and Retain Daily Nurse Staffing Information
Penalty
Summary
Surveyors determined that the facility failed to post daily nursing staffing information and did not retain 18 months of posted nursing data, as required. Upon entering the facility, surveyors observed that the nursing staffing document displayed at the receptionist's desk was outdated by several days. When questioned, the receptionist provided an updated posting within the hour. An interview with the DON confirmed that the daily posting for the observed day was missing and that the staff scheduler, who was responsible for posting, did not work weekends. The DON also acknowledged that the facility did not keep records of daily nursing staff postings for the previous six months and that records from previous ownership were not accessible. These findings were consistent across all five nursing units reviewed.
Failure to Investigate and Respond to Resident Grievances Timely
Penalty
Summary
The facility failed to ensure that all resident grievances were investigated and responded to in a timely manner, as required by policy. For one resident, repeated complaints about extended call light response times and concerns about staffing were reported multiple times to staff, but no formal grievance was documented or investigated by the DON. Call bell audit reports confirmed that this resident experienced wait times ranging from 30 minutes to 3 hours for call light responses. The DON acknowledged that a grievance was not written for these concerns, as she believed immediate resolution negated the need for formal documentation, despite the ongoing nature of the complaints. Another resident submitted grievances regarding long call light response times, including an incident where the call light was unanswered for two hours, prompting the resident to call out for assistance. Although staff education was provided to the involved staff member, there was no evidence that the incidents were fully investigated to determine root causes or that a plan of correction was implemented. Review of the grievance logs and interviews with facility staff revealed inconsistencies in the handling and documentation of grievances, with some forms not being completed or routed appropriately, and no timely responses provided to the residents involved.
Failure to Protect Resident from Misappropriation of Funds by Staff
Penalty
Summary
A facility failed to protect a resident from the misappropriation of personal funds by a staff member. The incident involved a resident who was transferred out of the facility for a change in condition, with the expectation of returning, so their belongings—including a credit card and driver’s license—remained at the facility. During this period, a Licensed Practical Nurse (LPN) employed through an agency took possession of the resident’s credit card and driver’s license. The LPN admitted to making unauthorized charges on the resident’s credit card, specifically purchasing a $100 Amazon gift card. This admission was made during an interview with the county sheriff’s office. The facility became aware of the misappropriation after the incident was reported, and the matter was investigated, confirming the unauthorized use of the resident’s funds by the staff member.
Failure to Monitor Resident After Warm Compress Application Resulting in Burn
Penalty
Summary
Facility staff failed to provide adequate supervision to prevent an accident involving a resident who requested a warm compress. Nursing staff applied the warm compress to the resident's right foot and secured it with an ace bandage. After application, there were no immediate observed issues with the resident's skin or complaints of discomfort. However, staff did not monitor the condition of the resident's skin following the application of the compress. Subsequently, a blister measuring 2.5 cm x 1.2 cm was observed on the resident's right lateral foot. The facility's investigation included an admission from nursing staff that they failed to monitor the resident's skin after the compress was applied. The Director of Nursing confirmed that this lack of monitoring occurred, which resulted in the resident sustaining a blister/burn injury.
Failure to Provide Adequate Staffing Leads to Delayed Call Light Responses
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in extended call light response times. Two residents reported waiting from 30 minutes up to several hours for assistance, particularly for incontinence care and toileting. One resident described waiting so long for help that accidents occurred, and another reported being left on the toilet for extended periods. Additionally, residents experienced delays in receiving assistance with meals and had bed linens left unchanged on shower days due to staff being unable to complete all required tasks. Staff interviews confirmed that staffing levels were often inadequate, with only one GNA assigned to each floor and a float GNA who was sometimes reassigned elsewhere. The Director of Nursing acknowledged that the ideal staffing level was not always met and could not provide a rationale for the prolonged call light response times when presented with audit data. Call bell audits and staffing schedules reviewed for specific periods showed consistent understaffing, correlating with the reported delays in resident care.
Significant Medication Errors: Insulin Administered to Non-Diabetic Residents
Penalty
Summary
Facility staff failed to ensure that residents were free from significant medication errors by inappropriately administering insulin to two residents who were not diabetic. One resident, who had a history of kidney/pancreas transplant and was legally blind, was monitored for hypoglycemia but did not have a diabetes diagnosis and was not prescribed insulin. This resident reported being injected with a needle without warning and was told by the LPN that insulin had been administered. The resident's glucose levels were subsequently monitored hourly, and glucose tablets were provided to address low blood sugar. The resident also indicated that another individual had experienced a similar incident. A second resident, with diagnoses including COPD, anemia, dysphagia, and heart disease but no diabetes, also received an insulin injection. This resident reported receiving a shot in the stomach and was unsure of its contents. Glucose monitoring was initiated, and the resident's blood sugar was checked and treated as needed. The LPN involved admitted to confusing residents and administering insulin to the wrong individual. The facility did not complete an internal investigation or report the incident to the Office of Health Care Quality, only notifying the Board of Nursing regarding the LPN's actions.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 335 citations issued within 25 miles in the last 12 months — including the 3 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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Williamsport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Homewood Living Williamsport | 1.2 mi | ★★★★★ | 17 | 0 |
| Creekside Center For Rehabilitation And Nursing | 5.5 mi | ★★★★★ | 34 | 1 |
| Julia Manor Nursing And Rehabilitation Center | 5.7 mi | ★★★★★ | 47 | 0 |
| Hagerstown Healthcare Center | 6.3 mi | ★★★★★ | 28 | 0 |
| Coffman Nursing Home | 6.8 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.