Inspection Reports for
Woodland Heights
1900 RAVINE ROAD,, WILLIAMSPORT, PA, 17701
Back to Facility Profile17 Reports
Inspection Report — Jan 14, 2025
Follow-Up
Date: Jan 14, 2025
Visit Reason
The inspection was an unannounced partial review conducted due to an incident at the facility.
Findings
The facility was found to have deficiencies related to medication administration documentation, specifically failures to document narcotic medication administration correctly. The submitted plan of correction was accepted and fully implemented.
Citations (2)
Failure to document the administration of narcotic medication on the Narcotic Medication Log Sheet as required.
Incorrect documentation of the date/time of medication administration on the Medication Administration Record.
Report Facts
Residents Served: 24
Current Hospice Residents: 2
Residents Age 60 or Older: 24
Residents with Physical Disability: 1
Residents with Mobility Need: 1
Total Daily Staff: 25
Waking Staff: 19
Inspection Report — Oct 10, 2024
Renewal
Date: Oct 10, 2024
Visit Reason
The inspection was conducted as a renewal and incident review of THE WILLIAMSPORT HOME & APARTMENTS, 3RD FLOOR facility on 10/10/2024.
Findings
The inspection identified multiple deficiencies including unsigned resident contracts, uncovered bed enabler bars posing entrapment hazards, unlabeled leftover food, dented food cans, incomplete fire drill records, missing or outdated medical evaluations, unsecured medications, medication record inaccuracies, medication errors, incomplete preadmission screening, delayed assessments, incomplete support plans, and incomplete resident record content. All deficiencies had plans of correction accepted and were implemented by 01/22/2025.
Citations (18)
Resident-home contract was not signed by the resident.
Resident bed enabler was uncovered presenting a possible entrapment hazard.
Leftover food (bacon) in kitchen refrigerator was not dated.
Two dented #10 cans in dry storage area.
Fire drill log did not indicate number of residents in home or evacuated at time of alarm.
Medical evaluation not completed within required timeframe for a resident.
Annual medical evaluation for a resident was not current at time of inspection.
A bottle of over-the-counter Advil was found unlocked in resident's room.
Medications belonging to a deceased resident were still stored in the home.
Resident glucometer was not calibrated to the correct date and medications were not available on the cart.
Medications for a resident were not listed on the Medication Administration Record (MAR).
Medication administration record incorrectly stated dosage; prescriber order and pharmacy label indicated different dosage.
Resident received another resident's medication in error.
Resident's preadmission screening form was not completed as required.
Initial assessment and support plan for a resident were not completed within 15 days of admission.
Resident's most recent additional assessment was not completed timely.
Resident's support plan did not indicate specific need, intended use, risks, or safety information for bed enabler device.
Resident record did not indicate if the resident has any identifying marks.
Report Facts
Residents Served: 22
Staffing Hours - Total Daily Staff: 22
Staffing Hours - Waking Staff: 17
Inspection Report — Feb 13, 2024
Follow-Up
Date: Feb 13, 2024
Visit Reason
The inspection was conducted as a follow-up to a complaint and incident reported at the facility, including a partial unannounced review on 02/13/2024 and an on-site visit on 03/05/2024.
Complaint Details
The visit was complaint-related, triggered by incidents including failure to report a resident fall and staffing concerns. The plan of correction was accepted and implemented, resolving the issues.
Findings
The facility was found to have deficiencies related to failure to report incidents timely, absence of direct care staff presence for a period, and incomplete updates to resident support plans following falls. The submitted plan of correction was accepted and fully implemented by 04/11/2024.
Citations (3)
Failure to report an incident of a resident fall to the Department within 24 hours.
Direct care staff was not present in the home for approximately 20 minutes while residents were present.
Resident support plans were not updated to reflect recent fall history.
Report Facts
Residents Served: 21
Current Hospice Residents: 1
Resident Support Staff: 19
Total Daily Staff: 40
Waking Staff: 30
Incident Reporting Timeframe: 24
Staff Absence Duration: 20
Inspection Report — Sep 21, 2023
Renewal
Date: Sep 21, 2023
Visit Reason
The inspection was conducted as a full, unannounced renewal inspection with an incident review on 09/21/2023.
Findings
The facility was found to have deficiencies related to incomplete annual training records for a staff member, outdated food labeling, and expired or unlisted medications. A plan of correction was submitted and fully implemented by 11/08/2023.
Citations (4)
The administrator could not provide the annual training for staff person A; only 9 hours of annual training were found for 2022 instead of the required 12 hours.
The administrator could not provide the 2022 annual training records for staff member A; records were misplaced when the prior training coordinator left.
An unlabeled, undated package of tator tots was found in the kitchen freezer.
Resident #1's medication Tusin DM expired on 5/23 and Preparation H was not listed on the resident's medication administration record.
Report Facts
Residents Served: 21
Total Daily Staff: 22
Waking Staff: 17
Annual Training Hours Found: 9
Annual Training Hours Required: 12
Inspection Report — Aug 25, 2022
Renewal
Date: Aug 25, 2022
Visit Reason
The inspection was conducted as a renewal visit to review the facility's compliance with licensing regulations.
Findings
The facility was found to have multiple deficiencies related to resident contracts, personal equipment, sanitary conditions, hot water temperature, egress routes, medication administration, and resident assessments. All deficiencies were corrected or had plans of correction implemented and accepted by the licensing authority.
Citations (14)
Resident-home contract for Resident #1 was not signed by the resident or offered for signature.
Resident #2's enabler bar was not covered, posing a possible limb entrapment risk.
Blood sugar monitor for Resident #3 had a dried red substance resembling blood on the monitor.
Hot water temperature in Resident #4's bathroom measured 120.8°F, exceeding the 120°F limit.
Emergency exit door on first floor East End was difficult to open and required excess force.
Resident #4 was not assessed by a qualified professional regarding ability to self-administer medications.
Resident #5's medications were stored unlocked in the resident's bedroom, and the resident did not lock the door when leaving.
Resident #6's prescription medication label did not include correct directions; medication was administered twice daily but order stated once daily.
Resident #6's over-the-counter paste was not labeled with the resident's name.
Resident #3's glucometer was not calibrated for the correct date and time.
Resident #6's medication administration record lacked strength information and blood sugar readings were not consistently recorded; Resident #7 also missed blood sugar readings.
Resident #1's assessment and support plan incorrectly indicated mobility status; resident is immobile but plan stated mobile.
Resident #6's assessment and support plan did not include need for enabler bar.
Resident #6's support plan incorrectly documented inability to self-administer medications despite evidence of self-administration.
Report Facts
Residents Served: 21
Staffing: 2
Staffing: 25
Staffing: 19
Hot Water Temperature: 120.8
Notice — Aug 27, 2021
Date: Aug 27, 2021
Visit Reason
The document serves as a renewal notification and license issuance for The Williamsport Home & Apartments, a Personal Care Home, following receipt of a renewal application dated June 8, 2021. It also advises that an annual onsite inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It confirms issuance of a regular license and states that enforcement action will be taken if noncompliance is found during future inspections.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
Inspection Report — Aug 24, 2021
Renewal
Date: Aug 24, 2021
Visit Reason
The inspection was an unannounced full renewal inspection with an incident review conducted on 08/24/2021.
Findings
The inspection identified deficiencies related to food storage temperature monitoring, medication storage and labeling, failure to follow prescriber's orders, and medication error reporting. Plans of correction were accepted and implemented with follow-up training and audits scheduled.
Citations (4)
The main kitchen's chest freezer for ice cream did not contain a thermometer.
Resident #1's inhaler medication was past the manufacturer's recommended use period after opening, and Resident #2's inhaler was not dated when opened.
Resident #1 did not receive their 2:00 PM medication on 8/17/21, failing to follow the prescriber's orders.
The medication error involving Resident #1's missed 2:00 PM dose was not reported to the resident, designated person, or prescriber as required.
Report Facts
Residents Served: 15
Current Hospice Residents: 2
Total Daily Staff: 15
Waking Staff: 11
Notice — Aug 6, 2020
Date: Aug 6, 2020
Visit Reason
The document serves as a renewal notification and license issuance for The Williamsport Home & Apartments, a Personal Care Home, following receipt of a renewal application dated June 2, 2020. It also advises that an annual onsite inspection will be conducted within the next twelve months.
Findings
No inspection findings are reported in this document. It confirms issuance of a regular license and states that enforcement action will be taken if noncompliance is found during the upcoming inspection.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-Term Living | Signed the renewal notification letter. |
Notice — May 31, 2019
Date: May 31, 2019
Visit Reason
This document serves as a renewal notification and license issuance for The Williamsport Home & Apartments, 3rd Floor, a Personal Care Home. It informs the facility of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It is a renewal notice and license certificate without any compliance or deficiency information.
Inspection Report — May 31, 2019
Annual Inspection
Date: May 31, 2019
Visit Reason
The inspection was an annual licensing inspection conducted by the Department’s Bureau of Human Services Licensing to assess compliance with 55 Pa. Code Chapter 2600 for Personal Care Homes.
Findings
The inspection identified multiple violations related to staff training, medication administration, food storage, fire department notification, and medication labeling. Plans of correction were approved with partial implementation status noted as of 9-9-19.
Citations (7)
2600.63a At least one staff person for every 50 residents must be trained in first aid and CPR. The home served 18 residents on 5/18/19 and no staff member was certified in first aid from 3pm-11pm.
2600.65f Direct care staff member A hired 6/16/15 did not receive medication self-administration training for the July 2017-June 2018 training year.
2600.103g Food shall be stored in closed or sealed containers. A cup of sherbert ice cream was located in the kitchen freezer without a covering.
2600.124 The home must notify the local fire department in writing of the address and assistance needed to evacuate. The notice did not indicate the capacity of the home.
2600.183d Only current prescription, OTC, sample and CAM for individuals living in the home may be kept in the home. Resident #1's 100u Novolog vial of insulin was opened on 4/21/19 and expired 28 days after opening.
2600.184a Resident #2's mupiricin gel did not have a pharmacy label attached.
2600.184b If OTC medications and CAM belong to the resident, they must be identified with the resident's name. Resident #2's vitafusion multi gummies did not include the resident's name.
Report Facts
Residents Served: 18
Inspection Report — Jun 5, 2018
Renewal
Date: Jun 5, 2018
Visit Reason
The inspection was a full renewal inspection conducted by the Department's Bureau of Human Services Licensing on June 5, 2018, for The Williamsport Home & Apartments 3rd Floor.
Findings
The inspection identified multiple violations related to staff training, fire safety inspections, fire drill documentation, and evacuation procedures. Plans of correction were submitted addressing each violation with steps for compliance and ongoing monitoring.
Citations (4)
55 Pa.Code 2600.65(g): Staff person A did not have annual training in the Older Adult Protective Services Act in 2017.
55 Pa.Code 2600.132(b): The home's most recent supervised fire drill and fire safety inspection by a fire safety expert occurred on 5/8/2017 and was not compliant with the regulation.
55 Pa.Code 2600.132(c): Fire drill logs did not always document minutes and seconds accurately for evacuation times, with some drills missing this detail.
55 Pa.Code 2600.132(d): The home conducted a fire drill on 5/9/2018 with a documented evacuation time of 5 minutes and 37 seconds but lacked a current fire safety letter allowing extension of maximum evacuation time.
Report Facts
Number of Residents Served: 20
Total Daily Staff: 21
Walking Staff: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Yvonne Laubach | Administrator | Named as Administrator and signer of plan of correction documents. |
| Amy Deluca | Department Representative | Conducted the inspection on 06/05/2018. |
Inspection Report — Jun 5, 2018
Renewal
Date: Jun 5, 2018
Visit Reason
The document is a renewal application and license for The Williamsport Home & Apartments, 3rd Floor, to operate as a Personal Care Home. The Department received the renewal application on June 5, 2018, and will conduct an onsite inspection within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It serves as a license renewal notification and states that an inspection will be conducted within twelve months to ensure compliance.
Report Facts
Inspection Report — Feb 20, 2018
Complaint Investigation
Date: Feb 20, 2018
Visit Reason
The inspection was conducted as a complaint investigation at The Williamsport Home & Apartments 3rd Floor.
Complaint Details
The inspection was triggered by a complaint. The violation related to hot water temperature was substantiated.
Findings
The inspection found a violation of 55 Pa.Code Chapter 2600 related to hot water temperature exceeding 120°F in resident-accessible areas. The facility submitted a plan of correction to address the issue and ensure ongoing compliance.
Citations (1)
55 Pa.Code §2600.89(b) - Hot water temperature in areas accessible to residents exceeded 120°F, with measurements of 124.3°F and 125°F in bathroom and kitchen sinks.
Report Facts
Number of Residents Served: 22
Hot Water Temperature: 124.3
Hot Water Temperature: 125
Hot Water Temperature: 124.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Yvonne Laubach | Administrator | Named as Administrator and signed plan of correction. |
| Ryan Novak | Department representative conducting the inspection. |
Inspection Report — Jun 27, 2017
Renewal
Date: Jun 27, 2017
Visit Reason
The inspection was a renewal licensing inspection conducted by the Pennsylvania Department of Human Services for The Williamsport Home & Apartments, 3rd Floor.
Findings
The inspection found violations related to fire hazard risks, specifically lint accumulation in the lint trap and dryer drum. A plan of correction was submitted to address these issues and ensure ongoing compliance.
Citations (1)
55 Pa.Code §2600.105(g)(1) requires removal of lint from the lint trap and dryer drum after each use. A lint wad was found in the lint trap of the Whirlpool dryer in the 3rd floor laundry room, posing a fire hazard.
Report Facts
Number of Residents Served: 24
Resident Support: 1
Total Daily Staff: 26
Waking Staff: 20
Residents Age 60 or Older: 24
Residents with Mobility Need: 1
Number of Hospice Residents in Past Year: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Yvonne Laubach | Administrator | Named in the violation report and plan of correction |
Notice — Jun 5, 2017
Date: Jun 5, 2017
Visit Reason
The document serves as a renewal notification for the Personal Care Home license and informs the facility of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It confirms issuance of a regular license following the renewal application.
Report Facts
Inspection Report — Jul 6, 2016
Renewal
Date: Jul 6, 2016
Visit Reason
The inspection was a renewal licensing inspection conducted on July 6, 2016, for The Williamsport Home & Apartments 3rd Floor Personal Care Home.
Findings
The inspection found multiple violations related to Personal Care Home regulations under 55 Pa.Code Chapter 2600, including missing adhesive bandages in the first aid kit, incorrect medication labeling, failure to report medication refusal, and improper use of correction tape in resident records. Plans of correction were submitted and partially implemented as of September 2016.
Citations (4)
55 Pa.Code 2600.96(a): The first aid kit in the third floor Medication Room did not include adhesive bandages.
55 Pa.Code 2600.184(a): The original container for prescription medications was labeled incorrectly; the Vitamin D3 medication label indicated administering one tablet daily instead of two.
55 Pa.Code 2600.187(c): The facility failed to notify the prescribing physician of a resident's refusal to take prescribed sodium chloride eye drops on 7/1/16.
55 Pa.Code 2600.251(b): Resident records contained correction fluid on a medical evaluation form, which is not permitted to ensure permanent and accurate documentation.
Report Facts
Number of Residents Served: 23
Total Daily Staff: 23
Waking Staff: 17
Number of Current Hospice Residents: 1
Number of Hospice Residents in Past Year: 2
Number of Residents 60 Years of Age or Older: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Yvonne Laubach | PCHA, LPN | Administrator and Legal Entity Representative named in multiple findings and plans of correction |
Inspection Report — Jun 7, 2016
Renewal
Date: Jun 7, 2016
Visit Reason
The document is a renewal application and license issuance for The Williamsport Home & Apartments, 3rd Floor Personal Care Home. The Department of Human Services will conduct an onsite inspection within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It serves as a license renewal notification and confirmation of capacity.
Report Facts
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