Inspection visit

Health inspectionFebruary 2, 2024

Williamsport Home, TheCMS #3956788 citations on this visit

8 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 8 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. 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 the apartments, or in their vehicle. Interview with Resident 315 on January 30, 2024, at 1:15 PM revealed that she does smoke but that the facility indicated they are a non-smoking facility, so she is not able to smoke here. She indicated that it was driving her nuts. Further interview of Resident 315 on January 31, 2024, at 10:30 AM after she requested to see the surveyor, revealed that she wanted to know what the facility smoking policy was and what the rules were related to smoking because she was hearing two different stories. She indicated that she was told on admission that the facility was non-smoking but that a nurse last night told her that staff and visitors smoke at the facility. She also indicated that she is manic depressive (a mental health disorder that causes extreme mood swings from emotionally high to emotionally low) and with her pain slowly getting under control, and that fact that she is not allowed to smoke she can feel herself slipping into a low spot. The Nursing Home Administrator and Director of Nursing were made aware of Resident 315's concerns related to smoking during a meeting on January 31, 2024, at 2:15 PM. They confirmed that staff and visitors could smoke at the facility in designated areas but that residents are not allowed to smoke. They also confirmed that residents are made aware of this on admission. The facility failed to ensure that a resident of the facility that desired to smoke, could smoke on (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 13 Event ID: 395678 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Williamsport Home, The 1900 Ravine Road Williamsport, PA 17701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0561 premises in the facility designated smoking areas that are available to visitors and staff. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.29(j) Resident rights Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395678 If continuation sheet Page 2 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Williamsport Home, The 1900 Ravine Road Williamsport, PA 17701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Potential for minimal harm Based on clinical record review and staff interview, it was determined that the facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for one of 24 residents reviewed (Resident 78). Residents Affected - Some Findings include: Review of Resident 78's clinical record revealed a Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated January 8, 2024, that indicated nursing staff assessed Resident 78 as being administered insulin injections. Review of Resident 78's physician orders did not include evidence of insulin medication. Interview with the Nursing Home Administrator, Director of Nursing, and Employee 1 (assistant director of nursing) on February 1, 2024, at 2:38 PM confirmed the MDS was incorrect and Resident 78 did not receive insulin during the lookback period. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395678 If continuation sheet Page 3 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Williamsport Home, The 1900 Ravine Road Williamsport, PA 17701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted 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 that the social worker met with Resident 314 and her son. The note indicated that the resident likes arranging flowers, puzzles, spending time with her grandchildren, walking, and gardening. The note indicated that the son revealed that Resident 314 does become both physically and verbally aggressive due to her dementia diagnosis. He also indicated that her behaviors can be activated by loud/noisy environments. He stated that when she is agitated it is best to give her space, if safe to do so, reapproach by using a calm soft voice, and for staff to provide cueing prior to any care or she may become combative if staff try to provide care without telling her or try to rush her. A behavioral progress note date January 29, 2024, at 2:07 PM revealed that Resident 314 continued with yelling and combativeness with staff. She was worse during morning care and when taking her to the bathroom. A behavioral progress note dated January 31, 2024, at 7:38 AM revealed that Resident 314 did well, but became anxious at times. She became severely agitated when asked to remain seated or when staff tried to wash the urine off her. She hit the nurse in the face two times. She was redirected to focus on sitting down and to get cleaned up and redressed. Review of Resident 314's baseline care plan revealed that the facility did not implement a person-centered behavioral care plan or interventions that were suggested by son when social services interviewed him. Interview with the Nursing Home Administrator, Director of Nursing and Employee 1, Assistant Director of Nursing, on February 1, 2024, at 2:42 PM confirmed that a care plan related to Resident 314's behaviors to include preventative interventions was not implemented until after the surveyor brought this to their attention on January 31, 2024. The facility failed to implement a person-centered baseline care plan to address Resident 314's behaviors. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395678 If continuation sheet Page 4 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Williamsport Home, The 1900 Ravine Road Williamsport, PA 17701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0655 28 Pa. Code 211.12(d)(1)(5) Nursing services Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395678 If continuation sheet Page 5 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Williamsport Home, The 1900 Ravine Road Williamsport, PA 17701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **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). Residents Affected - Some 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 revealed a current physician's order dated May 15, 2023, for staff to monitor their blood sugar at 6:00 AM every Monday for diabetes mellitus type 2 (body's inability to regulate blood sugar levels) and notify the physician if it was greater than 220 mg/dL (milligrams/deciliter). Review of Resident 76's clinical documentation revealed the following: On January 8, 2024, at 6:00 AM, her blood sugar was 259 mg/dL. On January 15, 2024, at 6:00 AM, her blood sugar was 237 mg/dL. On January 22, 2024, at 6:00 AM, her blood sugar was 352 mg/dL. On January 29, 2024, at 6:00 AM, her blood sugar was 244 mg/dL. There was no documentation indicating that staff notified Resident 34's physician regarding her blood pressure and/or pulse or Resident 76's blood sugar levels being outside of the prescribed parameters prior to surveyor identification. The surveyor reviewed the above information during an interview on February 2, 2023, at 8:15 AM with the Nursing Home Administrator. Clinical record review for Resident 99 revealed the facility admitted her on September 23, 2023. Review of Resident 99's initial Bowel and Bladder Incontinence assessment dated [DATE], revealed Resident 99's daughter indicated she did not use incontinence products at home. The assessment further revealed Resident 99's daughter informed staff that Resident 99 has a bladder stimulator (a device that may help people with an overactive bladder or those unable to control their urge to urinate. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395678 If continuation sheet Page 6 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Williamsport Home, The 1900 Ravine Road Williamsport, PA 17701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some device can either go under the skin of the buttock or on the inside of the ankle) implanted in her right buttocks for a history of bladder retention. Resident 99's daughter revealed the bladder stimulator gets charged once a month. The restorative nurse signed off on Resident 99's assessment on October 8, 2023. Further review of Resident 99's clinical record revealed the facility did not initiate a plan of care addressing Resident 99's bladder stimulator until November 20, 2023. The facility obtained a physician's order on November 21, 2023, to use a remote to check the bladder scanner weekly, if the color is green no charge is needed, if the color is orange, the bladder stimulator needs to be charged. A physician's order dated November 21, 2023, revealed staff are to remove the bladder stimulator charger from the dock (light should be green), snap the charger onto the belt, hold the charger near the stimulator (upper right buttocks) and you will hear one long tone when the charger is over the stimulator, and tighten the belt. If you hear three beeps and feel the charger vibrate, you need to realign the charger with the stimulator, when you hear three sets of rising tones you are done charging. Review of Resident 99's Treatment Administration Record (TAR, a form utilized to document resident nonmedication orders) dated November 2023 revealed the facility's first check of Resident 99's bladder stimulator was on November 21, 2023. Interview with Employee 4 (licensed practical nurse) on February 1, 2023, at 10:55 AM revealed that she was not officially trained on Resident 99's bladder stimulator. Interview with the Nursing Home Administrator, Director of Nursing, and Employee 1 (assistant director of nursing) on February 1, 2024, at 2:35 PM confirmed the findings for Resident 99's bladder stimulator. Interview with Employee 1 on February 2, 2024, at 8:25 AM confirmed the restorative nurse was aware of Resident 99's bladder stimulator on her admission to the facility. Employee 1 could provide no further documentation that staff were educated and competent to utilize Resident 99's bladder stimulator. 483.25 Quality of Care Previously cited 2/24/23 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395678 If continuation sheet Page 7 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Williamsport Home, The 1900 Ravine Road Williamsport, PA 17701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm **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). Residents Affected - Some 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 developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. Clinical record review for Resident 52 revealed the facility admitted her on August 7, 2020, with diagnoses including dementia with behavioral disturbances. A review of Resident 52's most recent annual MDS dated [DATE], indicated that the facility assessed Resident 52 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 52's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. Clinical record review for Resident 75 revealed the facility admitted her on May 20, 2021, with diagnoses including dementia with behavioral disturbances. A review of Resident 75's most recent annual MDS dated [DATE], indicated that the facility assessed Resident 75 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 75's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. Clinical record review for Resident 79 revealed the facility admitted him on October 24, 2023, with diagnoses including dementia with behavioral disturbances. A review of Resident 79's admission MDS dated [DATE], indicated that the facility assessed Resident 79 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 79's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395678 If continuation sheet Page 8 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Williamsport Home, The 1900 Ravine Road Williamsport, PA 17701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0744 Level of Harm - Minimal harm or potential for actual harm The findings were reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on January 31, 2024, at 2:25 PM. Further interview with the Director of Nursing and Employee 1 (assistant director of nursing) on February 2, 2024, at 8:21 AM confirmed the facility had no further documentation that the facility developed and implemented an individualized person-centered care plan to address Residents 26, 52, 75, and 79's dementia and cognitive loss. Residents Affected - Some 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395678 If continuation sheet Page 9 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Williamsport Home, The 1900 Ravine Road Williamsport, PA 17701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **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 confirmed the above findings for Resident 111. 28 Pa. Code 211.9 (j.1)(4)(5) Pharmacy services 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395678 If continuation sheet Page 10 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Williamsport Home, The 1900 Ravine Road Williamsport, PA 17701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. 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 for Resident 79 revealed a consultant pharmacist report dated October 25, 2023, revealed Resident 79 was recently admitted to the facility with an order for an antipsychotic medication Olanzapine 2.5 milligrams at night for depression, despite this medication not being classified as an antidepressant. The pharmacist noted this medication is more than likely being used for sleep. Antipsychotics have a boxed warning for increased risk of mortality in older adults with psychosis related to dementia. Additionally, they are associated with other potentially serious adverse effects including movement disorders, metabolic abnormalities, and orthostatic hypotension. The consultant pharmacist requested the facility attempt to discontinue the medication and if a medication is needed for sleep, to consider Trazodone (antidepressant medication). A consultant pharmacist report dated November 30, 2023, revealed Resident 79's clinical record contained no evidence of a diagnosis and/or documentation in the clinical record that supported the continued use of Tolterodine (medication used to treat overactive bladder) requesting the facility reevaluate continued use of/provide documentation in the clinical record, which supports clinical rationale for routine use. A consultant pharmacist report dated December 21, 2023, requested the facility reduce Resident 79's Tolterodine to 2 milligrams a day. Further review of Resident 79's clinical record revealed no evidence that Resident 79's physician addressed the October, November, or December 2023, consultant pharmacist recommendations. 483.45(c)(1)(2)(4)(5) Drug Regimen Review Previously cited deficiency 2/24/23 28 Pa. Code 211.2(d)(3)(8)(9) Medical director (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395678 If continuation sheet Page 11 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Williamsport Home, The 1900 Ravine Road Williamsport, PA 17701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 28 Pa. Code 211.9(k) Pharmacy services Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395678 If continuation sheet Page 12 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Williamsport Home, The 1900 Ravine Road Williamsport, PA 17701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. 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 1, 2023, at 8:37 AM revealed that there was a bag of chips with a use by date of October 6, 2020, in an upper cabinet. Observation of the therapy's kitchen on February 1, 2024, at 8:47 AM revealed three bottles of Maraschino cherry juice with a best by date of September 25, 2022, in an upper cabinet; a bottle of apple juice in the fridge with a best by date of October 26, 2023; an unopened case of Italian ice pops with a best by date of March 2023; and a case and a half of single serving sherbet, chocolate, and vanilla cups that were dried out, separated, or had the paper lids popped off the top in the freezer. Under the sink there were refrigerator bins. Observation of the second-floor pantry for the 300, 400, and 500-nursing units on February 1, 2023, at 9:03 AM revealed a refrigerator identified for resident use. There was no documentation that indicated staff were monitoring either the fridge or freezer temperatures. Neither the fridge or freezer thermometers were functioning and providing a reading at the time of the observation. Concurrent interview with Employee 6, dietary manager, confirmed the observations. This surveyor reviewed the above concerns with the Nursing Home Administrator during an interview on February 1, 2024, at 11:30 AM. 28 Pa. Code 201.14 (a) Responsibility of licensee FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395678 If continuation sheet Page 13 of 13

Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.

Citations

8 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0684GeneralS&S Epotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0561GeneralS&S Dpotential for harm
F561 - Self-determination
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
0641GeneralS&S Bno actual harm
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
0655GeneralS&S Dpotential for harm
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
0744GeneralS&S Epotential for harm
F744 - A resident who displays or is diagnosed with dementia, receives the
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
0755GeneralS&S Dpotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0756GeneralS&S Epotential for harm
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
0812GeneralS&S Epotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

FAQ · About this visit

Common questions about this visit

What happened during the February 2, 2024 survey of Williamsport Home, The?

This was a inspection survey of Williamsport Home, The on February 2, 2024. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at Williamsport Home, The on February 2, 2024?

Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·February 2, 2024