Williamsport Home, The
Williamsport Home, The in WILLIAMSPORT, PA — inspection on January 29, 2026.
Found 10 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of behavior monitoring recorded on Resident 9's documentation records for the months of April, May, June, and July 2025, revealed no behaviors documented for the resident.
There was no evidence of any further information to indicate the resident was in any emotional distress or having any behavioral concerns in the resident's clinical record.
Clinical record review of a pharmacist consultation report for Resident 9 dated July 22, 2025, revealed a recommendation of a GDR (gradual dose reduction) for Resident 9's dose of Quetiapine. A physician response to the recommendation dated July 23, 2025, revealed the physician declined to attempt a GDR of the medication noting family refused, as the rationale as to why the GDR would not be attempted.
There was no evidence to indicate a clinical contraindication was identified or documented as a rationale to not attempt the GDR.
There was no evidence Resident 9's antipsychotic medications were evaluated at least quarterly with documentation regarding continued clinical appropriateness nor was there any evidence to indicate Resident 9's had a GDR attempted or a clinical contraindication documented to not attempt a GDR based upon the consultant pharmacist's recommendation provided July 22, 2025.
The above information was relayed to the Nursing Home Administrator on January 29, 2026, at 11:26 AM. An interview with the Director of Nursing on January 29, 2026, at 1:18 PM confirmed that no further documentation could be found related to this concern. 28 Pa.
Code 201.18 (b)(1) Management 28 Pa.
Code 201.14 (a) Responsibility of licensee
395678 01/29/2026
Williamsport Home, The 1900 Ravine Road Williamsport, PA 17701
Review of the facility investigation into Resident 33's bruise revealed actions taken to prevent future occurrences were to apply Resident 33's derma sleeves as ordered and therapy to assess wheelchair positioning.
There was no witness statements obtained related to Resident 33's bruise until January 29, 2026, after the surveyors questioning.
The facility was also unable to provide documentation that therapy assessed Resident 33 for wheelchair positioning, or that they investigated if Resident 33's derma sleeves were in place as ordered.
Clinical record review revealed the facility admitted Resident 24 on December 13, 2023.
Nursing documentation dated December 17, 2025, at 5:38 AM revealed a nurse aide reported that while assisting Resident 24 in the bathroom, a discoloration of her abdomen was noticed.
The nurse noted a large discoloration measuring 17 cm by 7.5 cm at the widest point, with small, scattered areas across Resident 24's abdomen.
The nurse documented the area was light green and yellow, with light purple areas, showing signs of healing. Resident 24 was unable to explain how bruises happened due to her advanced dementia.
Review of the facility investigation into Resident 24's bruises revealed there were no witness statements obtained until January 29, 2026, after the surveyors questioning.
Interview with the Director of Nursing on January 29, 2026, at 9:45 AM confirmed these findings for Residents 33 and 24.
The facility failed to thoroughly investigate Resident 33 and 24's bruises to rule out abuse or prevent further injuries. 28 Pa.
Code 201.18(e)(1) Management 28 Pa.
Code 201.29(a)(c) Resident rights
395678 01/29/2026
Williamsport Home, The 1900 Ravine Road Williamsport, PA 17701
Observation of
January 2026 revealed that nursing staff initialed that Resident 29 had his hearing aids placed in his
use of his hearing aids.
Interview with Employee 6 on January 29, 2026, at 10:39 AM confirmed that she initialed for the application of Resident 29's hearing aids on this date, however, she did not ensure the placement of the hearing aids in Resident 29's ears.
Interview with Resident 119's daughter on January 26, 2026, at 12:11 PM revealed that Resident 119 had hearing aids, but he was not wearing them when she visited the previous Friday evening.
Clinical record review for Resident 119 revealed an admission MDS dated [DATE], that assessed that he had moderate difficulty hearing but did not capture that he utilized hearing aids.
The MDS CAA for communication triggered for staff to develop a plan of care to address Resident 65's potential communication deficits.Review of a plan of care initiated by the facility on January 23, 2026, to address Resident 119's potential communication deficits revealed no interventions to ensure the use of his hearing aids. An active physician's order dated January 14, 2026, indicated that Resident 119 had an audiology appointment scheduled for February 26, 2026, for a hearing aid check.
Review of Resident 119's physician orders and TAR revealed no directions to ensure the use of his hearing aids.
Observation of Resident 119 on January 27, 2026, at 9:30 AM revealed that he was not wearing his hearing aids. Resident 119 stated that his hearing aids were in a charger on his dresser.
Observation of Resident 119 on January 28, 2026, at 3:33 PM revealed that he was not wearing his hearing aids. Resident 119 confirmed that his hearing aids were in the charger on his dresser.
Observation of Resident 119's room on January 29, 2026, at 10:44 AM revealed that Resident 119 was out of his room for his skilled therapy treatment, but his hearing aids were in the charger on his dresser furniture.
Interview with Employee 6 on January 29, 2026, at 10:39 AM revealed that Resident 119 had hearing aids and that he typically, doesn't give problems with his (hearing aids).
Employee 6 denied ensuring that he had hearing aids in place before leaving his room for his skilled therapy treatment.
The surveyor reviewed the above concerns regarding hearing aid use for Residents 29, 65, and 119, during an interview with the Nursing Home Administrator on January 29, 2026, at 12:00 PM. 28 Pa.
Code 211.12(d)(1)(5) Nursing services
395678 01/29/2026
Williamsport Home, The 1900 Ravine Road Williamsport, PA 17701
Observation of Resident 115's room on January 27, 2026, at 8:51 AM revealed no medical equipment to perform a remote cardiac pacemaker assessment.
Interview with Resident 115 on January 27, 2026, at 10:24 AM confirmed that she had an internal cardiac pacemaker. Resident 115 stated that she had a [NAME] machine at her home, but was told to not bring it to the facility. Resident 115 stated that she has the [NAME] machine, next to her bed at her home and that she believes that the machine does continuous monitoring of her pacemaker. Resident 115 stated that should her pacemaker malfunction, the staff at her doctor's office would call her. Resident 115 stated that, this is her second one (pacemaker), the battery got weakened after 10 years in the other one.
The surveyor requested the plan of care to address Resident 115's remote pacemaker monitoring while in the facility during an interview with the Nursing Home Administrator and the Director of Nursing on January 27, 2026, at 2:00 PM.
Social services documentation dated January 27, 2026, at 5:11 PM (following the surveyor's questioning) revealed that social services staff spoke with Resident 115's responsible party regarding the [NAME] pacemaker machine. Resident 115's responsible party indicated that she would bring the device to the facility the next day.Interview with the Director of Nursing on January 28, 2026, at 11:38 AM confirmed that the facility failed to arrange for the use of Resident 115's pacemaker monitoring device before the surveyor's questioning.
Interview with the Nursing Home Administrator on January 29, 2026, at 9:50 AM confirmed that Resident 115's plan of care, revised January 28, 2026, now included the use of a, [NAME] transmitter in her room, however, the plan of care was missing pertinent information (e.g., necessary distance from resident to function, method of communication such as Bluetooth or Wi-Fi connectivity, schedule of monitoring such as at hour of sleep, and applicable cardiac provider's contact information).
Clinical record review revealed the facility admitted Resident 7 on February 4, 2022, with diagnoses including presence of cardiac pacemaker. A current physician order-initiated on October 3, 2022, ordered Resident 7 to receive an EKG (an electrocardiogram, a noninvasive test that records the electrical activity of the heart, to diagnosis various heart conditions) every three months for his pacemaker.
Further review of Resident 7's clinical record revealed a care plan-initiated February 23, 2022, noting Resident 7 has a potential for decreased cardiac output related to his pacemaker, with an intervention for an EKG every three months.
Review of documentation provided by the facility of Resident 7's EKGs revealed there was no documentation of Resident 7 receiving an EKG from April 8, 2025, to October 5, 2025 (6 months).
The facility failed to provide the highest practical care to Resident 7 related to his pacemaker.
Interview with the Director of Nursing on January 29, 2026, at 10:04 AM confirmed these findings. 28 Pa.
Code 211.12(d)(1)(3)(5) Nursing services
395678 01/29/2026
Williamsport Home, The 1900 Ravine Road Williamsport, PA 17701
The facility failed to implement pressure relieving interventions to prevent a pressure area on Resident 3's left elbow.
The nursing home administrator was made aware of the above noted concerns related to Resident 3's pressure ulcer on January 29, 2026, at 11:30 AM. 28 Pa.
Code 201.18(b)(1)(3) Management 28 Pa.
Code 211.5(f)(ii)(iv)(ix) Medical records 28 Pa.
Code 211.10(a)(d) Resident care policies 28 Pa.
Code 211.12(d)(1)(5) Nursing services
395678 01/29/2026
Williamsport Home, The 1900 Ravine Road Williamsport, PA 17701
Review of her MDS for the dates of May 8, 2025, August 5, 2025, and September 26, 2025, revealed that Resident 3 had no impairment of her upper extremities.
Review of her annual MDS dated [DATE], noted staff assessed Resident 3 as having impairment to ROM of one side of her upper extremities.
Further clinical record review for Resident 3 revealed that a passive range of motion program (PROM, movement of a body part by another to maintain a resident's ability) was initiated to her bilateral upper extremities on July 24, 2025, and a splint was ordered to her left hand on October 1, 2025.
Review of Resident 3's PROM program documentation for the months of November and December 2025, and January 1-26, 2026, revealed the followings dates that her PROM program was not documented as being done: November 21, 24, and 30, 2025, dayshift.
December 1, 3, 5, and 6, 2025, evening shift and December 5, 9, 14, and 29, 2025, dayshift.
January 6, 15, and 25, 2025, evening shift and January 2, 10, 11, 15, 16, 24, 25, and 26, 2026, dayshift.
The above noted information was reviewed with the Director of Nursing on January 29, 2026, at 1:00 PM.
The Nursing Home Administrator was made aware at 1:15 PM.
The facility failed to ensure that Resident 3 received her ordered PROM program in order to prevent decline or maintain her range of motion. 28 Pa.
Code 211.12(d)(1)(5) Nursing services
395678 01/29/2026
Williamsport Home, The 1900 Ravine Road Williamsport, PA 17701
way that maximizes each resident's well being.
failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to
employees reviewed for competencies (Employees 2, 3, 4, and 5).Findings include: A review of the facility documentation revealed that the facility had a total of 17 residents with indwelling urinary catheters (insertion of a tube into the bladder to remove urine) and 28 residents with dressing changes (treatment to and changes in the covering of wounds). A request for nursing staff competencies for dressing changes and catheter care revealed the facility was unable to provide competencies for these for Employees 2 and 3 (licensed practical nurses), and Employees 4 and 5 (registered nurses).
The findings were reviewed with the Nursing Home Administrator and Employee 1 (registered nurse/staff development) on January 29, 2026, at 10:05 AM.
They confirmed the facility could provide no documentation that ensured Employees 2, 3, 4, and 5 had specific competencies and skill sets to care for the resident needs listed above. 28 Pa.
Code 201.20 (a) Staff Development
395678 01/29/2026
Williamsport Home, The 1900 Ravine Road Williamsport, PA 17701
The facility failed to ensure an appropriate physician response to Resident 19's pharmacy review as noted above. 483.45(c)(4) Pharmacy reviewPreviously cited 2/28/25 28 Pa.
Code 211.9 (d)(k) Pharmacy services 28 Pa.
Code 211.12(d)(3)(5) Nursing services
395678 01/29/2026
Williamsport Home, The 1900 Ravine Road Williamsport, PA 17701
The surveyor reviewed the above concerns regarding Resident 87 and 119's pneumococcal immunizations during an interview with the Nursing Home Administrator and the Director of Nursing on January 28, 2026, at 2:30 PM. 28 Pa.
Code 211.12(d)(1)(3)(5) Nursing services
395678 01/29/2026
Williamsport Home, The 1900 Ravine Road Williamsport, PA 17701
Based on a review of select facility policies and procedures and staff interview it was determined
at a minimum that staff were provided education regarding the benefits and potential risks associated with COVID-19 vaccine, that staff were offered the COVID-19 vaccine, or information on obtaining COVID-19 vaccine, for one of one employee reviewed for COVID-19 vaccination (Employee 8).Findings include: The facility policy entitled, COVID-19-Covid Plan, last reviewed without changes on December 30, 2025, revealed that the facility would vaccinate residents and health care professionals (HCP) against SARS-CoV-2 (COVID-19) as part of their plan's core principles.
The facility would encourage everyone to remain up to date with all recommended COVID-19 vaccine doses. HCP should be offered resources and be counseled about the importance of receiving the COVID-19 vaccine.
Interview with Employee 8 (environmental services director) on January 29, 2026, at 10:50 AM revealed that she believed that she was up to date with all her recommended COVID-19 immunizations.
Employee 8 stated that it was important to her to have all available immunizations as she had medical conditions that put her at risk for infections.
Employee 8 presented a COVID-19 immunization card to the surveyor that indicated that her last COVID-19 immunization was in 2022.
Employee 8 stated that she received additional vaccines from Employee 7 at the facility, but her card had not been updated.
Interview with Employee 7 (registered nurse/infection preventionist) on January 29, 2026, at 11:20 AM revealed that data submitted to NHSN (Centers for Disease Control and Prevention's National Healthcare Safety Network) confirmed that Employee 8 had no additional COVID-19 immunizations after October 17, 2022.
Employee 7 denied administering a COVID-19 immunization to Employee 8 and that she likely administered an influenza immunization to Employee 8.
Employee 7 confirmed that the facility had no evidence that Employee 8 was offered resources or was counseled about the importance of receiving ongoing COVID-19 vaccines, the risks and benefits of the vaccines, or was offered a COVID-19 immunization after October 17, 2022.
Employee 7 confirmed that the facility had no process to obtain ongoing COVID-19 immunization data for staff after initial information is obtained during the hiring process to ensure accurate COVID-19 vaccine status of staff and related information is submitted to the NHSN as required. 28 Pa.
Code 201.14(a) Responsibility of licensee 28 Pa.
Code 211.12(d)(1) Nursing services