Williamsport Home, The

Based on observation and staff and resident interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to ensure a clean, safe, and orderly environment on 3 of six nursing units (300 400, and 500 Nursing Units, Residents 14, 3, 81, and 84) and at the facility's main entrance. Findings include: Observation of the 300 Hall Nursing Unit on the following dates and times revealed the following: On February 25, 2025, at 1:31 PM there was a strong odor of urine in Resident 14's room. On February 26, 2025, at 11:27 AM and February 27, 2025, at 1:00 PM and there was an odor of urine in Resident 14's room. Observation of the main entrance to the facility on February 25, 2025, at 1:02 PM and February 27, 2025, at 8:33 AM and 12:48 PM, revealed the following: One medical face mask was discarded on the ground and two others discarded in the landscape adjacent to the main entrance of the facility. A used tissue discarded in the planter next to the main entrance. An overflowing garbage can. Multiple cigarette butts discarded on the ground and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and resident and staff interview, it was determined that the facility failed to ensure that pain management was provided that was consistent with professional standards of practice for one of one resident reviewed (Resident 84). Findings include: Interview with Resident 84 on February 26, 2025, at 11:24 AM she indicated that she has pain and that it is not controlled with the medication that they give her. She said her pain is in her legs and that it is worse when they move her. She indicated that she usually would ask staff for her pain medication and if it is time they will give it to her. A physician's progress note dated December 17, 2024, at 6:08 PM revealed that Resident 84 was seen by orthopedics related to her left leg contracture and they reported that her extremity is bone on bone and that she is not a surgical candidate. They recommended palliative care and pain management. The physician discontinued her Tramadol (a medication used to treat moderate to severe pain) and increased her dose of Oxycodone (a medication used to treat moderate to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, clinical record review, and staff and resident interview, it was determined that the facility failed to assess for the risk of side rail entrapment for 6 of 11 residents reviewed for accident hazards (Residents 3, 9, 12, 38, 71, and 262), and review the risk and benefits of side rail utilization with the resident or resident representative, and receive consent for the use of side rails for 5 of 11 residents reviewed for accident hazards (Residents 3, 9, 12, 59, 71). Findings include: Observation of Resident 12's room on February 26, 2025, at 11:23 AM revealed that there were bilateral grab bars observed on the bed. Clinical record review for Resident 12 revealed that the facility completed an enabler bar assessment, review of potential risks, and consent on November 29, 2023. The facility completed an enabler bar entrapment evaluation on December 27, 2023, which indicated that they passed for potential entrapment for zones one (within the rail), two (between the bottom of the rail and top of compressed mattress), three (between the edge of the mattress and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of select facility policies, clinical record review, and staff interview, it was determined that the facility failed to ensure a timely physician response to consultant pharmacist recommendations for three of five residents reviewed (Residents 21, 57, and 64). Findings include: The facility policy Monthly Medication Regimen Review, last reviewed on February 11, 2025, revealed that if an identified irregularity requires urgent action, the pharmacist will immediately report the irregularity to the Director of Nursing or designee and the attending physician by phone. Review of a medication regimen review for Resident 57 dated September 26, 2024, revealed a Consultation Report, which noted the pharmacist made a recommendation of a gradual dose reduction (GDR) for the resident's Duloxetine (a medication used to treat depression, anxiety, and sometimes pain). Further review of this documentation for Resident 57 revealed that the physician had responded to the recommendation by declining it, signing, and dating the document on November 15, 2024. The documentation was also…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and staff interview, it was determined that the facility failed to assess and implement interventions to maintain a resident's continence status for one of four residents reviewed (Resident 9). Findings include: The MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) Resident Assessment Indicators (RAI) 3.0 Manual, Section H indicated that each resident who is incontinent or at risk of developing incontinence should be identified, assessed, and provided with individualized treatment (medications, non-medicinal treatments and/or devices) and services to achieve or maintain as normal elimination function as possible. Clinical record review for Resident 9 revealed that since July 3, 2024, Resident 1 had a physician's order to transfer and ambulate with use of a gait belt, a rolling walker, and one staff assistance. The facility completed an annual MDS assessment on January 24, 2025. The facility identified that Resident 9 was moderately impaired, with a BIMS (Brief Interview for Mental Status,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to store oxygen and respiratory care equipment consistent with professional standards of practice for two of two residents reviewed for respiratory care (Residents 28 and 74). Findings include: Observation of Resident 28 on February 25, 2025, at 2:43 PM revealed a nebulizer machine (a small machine that turns liquid medicine into a mist that can be easily inhaled) sitting on the resident's stand beside her bed. A mouthpiece connected to the tubing coming from the machine was observed hanging down in front of the stand uncovered. Resident 28 indicated they received nebulizer treatments two or three times a day. An observation of Resident 28 on February 26, 2025, at 9:25 AM revealed the nebulizer machine again sitting on the resident's stand beside her bed with the mouthpiece hanging down in front of the stand uncovered. Clinical record review for Resident 28 revealed the resident was ordered Ipratropium-Albuterol Solution (a liquid) to inhale by mouth using a nebulizer every…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and resident and staff interview, it was determined that the facility failed to administer medication to a resident based on professional standards of practice resulting in the potential for a significant medication error for one of 5 residents reviewed for administration of medications (Resident 262). Findings include: In an interview with Resident 262 on February 25, 2025, at 2:03 PM the resident indicated there was a mix up with her medications Zofran (a medication used to treat nausea and vomiting) and Ativan (a medication used to treat anxiety) from when she was at the facility the first time, and she should not have had them the second time. Clinical record review for Resident 262 revealed the resident was admitted to the facility on [DATE], and sent to the hospital after a change in condition on January 26, 2025. A progress note for Resident 262 dated January 27, 2025, at 12:39 PM noted facility staff met with a family member of the resident who was in the facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interview, it was determined that the facility failed to ensure appropriate medication security for one of six nursing units (300 Hall Nursing Unit). Findings include: Observation of the 300 Hall Nursing Unit on February 25, 2025, revealed the following: At 8:48 AM, upon arrival to the 300 Hall Nursing Unit, the surveyor observed the unit's medication cart unlocked while it was near the soiled utility room. No licensed staff were observed in the vicinity. There were several unlicensed staff pushing residents in wheelchairs past the medication cart while it was unlocked. At 8:49 AM, Employee 1, licensed practical nurse, returned to the medication cart from down the hallway and out of view of the medication cart. Employee 1 left the 300 Hall Nursing Unit's medication cart while they were away from the medication cart and did not have direct visualization of the medication cart. Interview on February 25, 2025, at 9:18 AM with Employee 1 acknowledged that their medication cart was left unsecure while they were away from it. The findings were reviewed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to assist a resident to obtain routine dental care for one of two residents reviewed for dental concerns (Resident 84). Findings include: Interview and observation of Resident 84 on February 26, 2025, at 11:06 AM while she was in bed revealed that she had her own teeth. Resident 84 indicated that she had not seen a dentist since she had been in the facility. Clinical record review for Resident 84 revealed that her current payment source was the state Medicaid benefit. Further clinical record review for Resident 84 revealed no evidence of her receiving dental services over the past 12 months. Interview of the Director of Nursing on February 28, 2025, at 8:00 AM revealed that there was no evidence that Resident 84 received dental care or that she was offered dental care and refused treatment. The facility failed to provide Resident 84 with routine prophylactic dental cleanings as covered under the State plan. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff and resident interview, it was determined that the facility failed to ensure accurate clinical documentation for one of 24 residents reviewed (Resident 100). Findings include: Clinical record review for Resident 100 revealed the resident was admitted to the facility on [DATE]. Review of the resident's list of active diagnosis revealed Post Traumatic Stress Syndrome (PTSD) added on January 22, 2025. Review of an admission MDS (Minimum Data Set - an assessment completed at periodic intervals of time to assess resident care needs) dated January 28, 2025, for Resident 100 revealed the resident was listed as having a diagnosis of PTSD. Interview with Resident 100 on February 25, 2025, at 12:02 PM revealed the resident indicated hearing sirens specifically were traumatizing to him due to his history, but stated he did not have an official diagnosis of PTSD from a psychologist or medical professional. In an interview with Employee 2, social services, on February 27, 2025, at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and staff interview, it was determined that the facility failed to implement a comprehensive person-centered care plan regarding pressure injury risk for one of four residents reviewed (Resident CR1). Findings Include: Review of Resident CR1's closed clinical record revealed a Minimum Data Set Assessment (MDS, an assessment done at specific intervals to determine care needs) dated March 7, 2024, revealed that the facility assessed Resident CR1 as being at risk of developing pressure ulcers and/or injury and indicated that a care plan regarding this risk would be developed. Review of Resident CR1's plan of care revealed that the facility did not develop a plan of care to address his risk of pressure ulcer and/or injury until April 3, 2024, two days after his discharge from the facility. The above findings were reviewed and acknowledged during a phone interview with the Administrator and Director of Nursing on May 8, 2024, at 1:30 PM. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding surgical incision assessments and treatments for one of 4 residents reviewed (Resident CR1). Findings include: The policy entitled Wound Treatment Guidelines, provided as the policy in effect for the facility as of March 1, 2024, indicated that the facility will report any changes to the surgeon such as drainage, pain, redness, or warmth. The policy did not indicate how often the facility will assess a surgical incision for signs and symptoms of infection. Review of Resident CR1's closed clinical record revealed that the facility admitted him on March 1. 2024. An admission nursing assessment dated [DATE], indicated that Resident CR1 was admitted with a thoracic (an area on the spine below the neck to below the shoulder blades) incision with 25 staples with black crusted drainage present. A nursing note dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of clinical records, review of select forms and documents, and staff interview, it was determined that the facility failed to ensure an effective procedure for acquiring and dispensing medications for five of six residents reviewed (Residents 1, 2, 3, 4, and 6). Findings include: Documents provided by the Director of Nursing on March 29, 2024, at 9:30 AM identified the procedure for obtaining medications for new admissions, effective March 18, 2024, indicates that if the facility orders medications by 11:00 AM, the pharmacy will depart at 2:20 PM to deliver Monday through Friday. If orders are completed by 9:00 PM, pharmacy will depart at 12:30 AM to deliver Monday through Friday. The procedure also indicates that there is a 5 Step Order Process in which nursing staff shall determine what time the resident medication is due, then determine when the delivery time would be for the pharmacy. If the delivery time is after the time the dose is due, staff are to determine availability of the medication from their Omnicell (a backup inventory of medications stored on-site…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered vital signs, interventions, and treatments for three of 24 residents reviewed (Residents 34, 76, and 99). Findings include: Clinical record review for Resident 34 revealed a current physician's order dated August 23, 2023, for staff to monitor their blood pressure and heart rate at 11:00 AM on Wednesdays and fax results to the physician if the heart rate was greater than 120 beats per minute (bpm) or less than 60 bpm and if the systolic blood pressure (pressure when the heart contracts) was greater than 160 mmHg (millimeters of Mercury) or less than 110 mmHg. Review of Resident 34's clinical documentation revealed that staff completed blood pressures and heart rates on the following dates: August 23, 2023, at 11:00 AM heart rate 56 bpm November 15, 2023, at 11:00 AM blood pressure of 104/72 mmHg Clinical record review for Resident 76…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by four of four residents reviewed (Residents 26, 52, 75, and 79). Findings include: Clinical record review for Resident 26 revealed the facility admitted her on December 6, 2023, with diagnoses including severe dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life) with agitation and dementia with behavioral disturbances. A review of Resident 26's admission Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated December 12, 2023, indicated that the facility assessed Resident 26 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 26's care plan revealed that there was no indication that the facility had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure an appropriate response to consultant pharmacist recommendations for three of five residents reviewed for potentially unnecessary medications (Residents 37, 75, and 79). Findings include: Clinical record review for Resident 37 revealed a consultant pharmacist report dated June 26, 2023, requesting the facility monitor the effectiveness and potential adverse effects of Resident 37's Cymbalta (antidepressant medication) and ensure it was documented in the clinical record regularly. Further review of Resident 37's clinical record revealed no evidence that the facility addressed the June 2023 consultant pharmacist recommendation. Clinical record review for Resident 75 revealed a consultant pharmacist report dated April 30, 2023, that requested a gradual dose reduction of Resident 75's Zoloft. Further review of Resident 75's clinical record revealed Resident 75's physician did not address the April 2023 consultant pharmacist recommendation until July 11, 2023. Clinical record review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interview, it was determined that the facility failed to store food in a manner to prevent the potential spread of foodborne illness in the therapy suite and the facility's pantry for six of six nursing units (100, 200, 300, 400, 500 and Ravine Ridge Nursing Units). Findings include: Observation of the 100-nursing unit's pantry on February 1, 2023, at 8:24 AM revealed several items under the sink, including two containers of cleaning wipes, several glass vases, a lap blanket, two one-gallon containers of water, and a basin. Observation of the 200-nursing unit's pantry on February 1, 2023, at 8:30 AM revealed several items under the sink, including several vases, a small trash can, a broken glass, and old Christmas decorations. Observation of the Ravine Ridge nursing unit's pantry on February 1, 2023, at 8:34 AM revealed several items under the sink, including cleaning wipes, two containers of hand soap, a container of dish soap, vases, and a plastic piece for a refrigerator. Observation of the Ravine Ridge nursing unit's satellite kitchen on February…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of select facility policy and procedures, observations, and resident and staff interviews, it was determined that the facility failed to ensure that residents could make choices about aspects of their lives that were significant to them, such as smoking, for one of 32 residents reviewed (Resident 315). Findings include: The facility policy entitled, Smoking Policy Skilled Nursing Facility, last reviewed without changes on January 25, 2024, revealed the facility is a smoke free building. The policy of the facility was to ensure that smoking was only permitted in a designated area and was done in a safe manner. New residents will be informed that the facility is smoke free; and they are welcome to reside here but may not smoke. The procedure indicated that the skilled nursing center has a designated smoking area on the porch outside the main lobby for visitors to smoke. Staff are permitted to smoke during break times in areas indicated by signs as a designated smoking area to include the smoke shack off the skilled nursing facility and the designated smoking areas at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement a baseline care plan that included instructions needed to provide effective care for one of four residents reviewed (Resident 314). Findings include: Clinical record review for Resident 314 revealed that the facility admitted her on January 25, 2024, with diagnoses of dementia (loss of memory, language, problem-solving and other thinking abilities that interfere with daily life), mood disturbance (feelings of distress or sadness), psychotic disturbance (a mental disorder characterized by a disconnection from reality), and anxiety (intense, excessive, and persistent worry and fear about everyday situations). Further clinical record review for Resident 314 revealed a behavioral progress noted dated January 28, 2024, at 9:58 AM that indicated the resident was hitting the nurse and nurse aide multiple times during morning care. The note indicated she was very combative and unable to redirect. A social service progress noted dated January 29, 2024, at 10:10 AM revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed clinical record review, review of select policies and procedures, and staff interview, it was determined that the facility failed to ensure reconciliation of controlled medications upon discharge for one of three residents reviewed (Resident 111). Findings include: Review of Resident 111's closed clinical record revealed that she expired and was discharged from the facility on [DATE]. Resident 111 had current physician orders for Oxycodone (a narcotic used to treat pain) 5 mg (milligrams) every four hours as needed for pain and Ativan (medication used to treat anxiety) 0.5 mg two times a day as needed for anxiety. There was no documented evidence in Resident 111's closed clinical record to indicate that the facility accounted for the disposition of her controlled medications upon her discharge. There was no documented evidence to indicate if the controlled medications were destroyed, returned to the pharmacy, or diverted. Interview with the Director of Nursing on February 2, 2024, at 8:13 AM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.