Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of June 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.
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.
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.
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.
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.
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 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.
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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.
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Nursing homes near Williamsport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| 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 | — | 41 | 0 |
| Hagerstown Healthcare Center | 6.3 mi | — | 27 | 0 |
| Coffman Nursing Home | 6.8 mi | — | 0 | 0 |
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