Williamsport Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Williamsport Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Dec 10, 2025

  Based on record review and interview it was determined that the facility failed to have a process in place to ensure that residents' choice to not have cardiopulmonary resuscitation (CPR) was honored. This was evident for 2 (#8 and #7) of 2 residents reviewed for advanced directives. As a result of these findings, a state of immediate jeopardy (IJ) was declared on [DATE] at 3:20 PM and an IJ summary tool was provided to the facility at that time. The facility submitted the first draft of their plan to remove the immediacy on [DATE] at 4:43 PM and it was not accepted. The facility submitted a second draft at 5:35 PM, and it was not accepted. […]

• Actual harm, isolatedF684Jun 24, 2022

  Based on surveyor observation, record review, and interviews with residents and staff, it was determined that the facility staff failed to ensure that care and services were provided to assist all residents in achieving their highest practicable level of wellbeing. This was evidenced by: 1) facility staff's failure to ensure that each resident received treatment and care in accordance with professional standards of practice as evidenced by a nurse providing a treatment without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #74, #59) out of 7 residents selected for unnecessary medication review, 3) the facility staff's failure to ensure that arm protectors were provided as prescribed by the physician for 1 (#35) of 13 residents reviewed for Abuse, 4) the facility staff failure to… […]

• No harm, potential for more than minimal, widespreadF727Aug 26, 2026

  Based on review of pertinent documentation and interviews it was determined that the facility failed to ensure a registered nurse (RN) was on duty in the facility for 5 consecutive 8 hour shifts in a row. This deficient practice has the potential to affect all residents. The findings include:Maryland state regulations require RN coverage 24 hours a day 7 days a week.On 8/19/26 at 2:17 PM the Schedule Coordinator (Staff #17) was interviewed in regard to staffing goals. When asked if a goal was to have a RN on duty every shift, Scheduler #17 responded: I try, I feel for the most part we are reaching that goal. Surveyor and Scheduler #17 then reviewed the weekend assignment sheets for the month prior to the start of the survey (7/18-8/16/26). […]

• No harm, potential for more than minimal, widespreadF585Jul 24, 2025

  Based on interviews and a review of pertinent documents, the facility failed to follow the required procedure for addressing residents' grievances. This was evident for 1 (Resident #6) out of 3 residents reviewed for personal property during a survey.The findings include:On 7/15/2025 at 10:09 AM, Resident #6, who was admitted to the facility for rehabilitation, reported that one of her/his long pants was missing. S/he stated that this had been reported to a facility staff member.On 7/17/2025 at 11:20 AM, the Director of Social Services and Discharge Planning (Staff #3) was interviewed. She confirmed that she did not have a grievance form regarding the resident's missing pants.On 7/17/2025 at 11:24 AM, the Director of Social Work & Discharge Planning (Staff #3) was interviewed. […]

• No harm, potential for more than minimal, widespreadF801Jul 24, 2025

  Based on interviews with facility staff and review of the dietary supervisor credentials, it was determined the facility staff failed to ensure a full-time qualified dietetic service supervisor for oversight of food preparation and daily kitchen operation.The findings include:On 7/15/25 at 8:10AM an observation of the facility kitchen was made. During the interview the kitchen manager (Staff #13) reported that her highest level of credentials were in serv safe. She reported that she was in the process of taking the Certified Dietary Manager (CDM) class. She reported that she received consultation from the Regional Dietary Manager. On 7/18/25 at 10:17 AM an interview was conducted with the Regional Dietary Manager (Staff #31). […]