Inspection Reports for Williamsport Nursing and Rehabilitation
200 SHORT ST, IN, 47993
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 2, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a mixed pattern, with some citations primarily involving wound care, life safety code issues, medication administration, and food safety practices. Complaint investigations were mostly unsubstantiated or substantiated without deficiencies, except for one substantiated complaint in November 2024 related to improper wound vacuum placement. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility appears to have addressed many prior issues, as recent inspections show fewer deficiencies compared to earlier ones.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
5.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
38% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
100% occupied
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 63
Capacity: 63
Deficiencies: 0
Jun 2, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00458947.
Findings
No deficiencies related to the allegations are cited. Williamsport Nursing and Rehabilitation was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Investigation of Complaint IN00458947.
Complaint Details
Complaint IN00458947 - No deficiencies related to the allegations are cited.
Report Facts
Census Bed Type: 63
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 36
Census Payor Type - Other: 25
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 22, 2025
Visit Reason
Paper compliance review to the Investigation of Complaint IN00446310 completed on November 21, 2024.
Findings
Williamsport Nursing and Rehabilitation was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Complaint Details
Investigation of Complaint IN00446310; paper compliance review completed and found in compliance.
Report Facts
Complaint ID: 446310
Inspection Report
Complaint Investigation
Census: 65
Capacity: 65
Deficiencies: 1
Nov 21, 2024
Visit Reason
This visit was for the investigation of Complaint IN00446310 related to federal/state deficiencies concerning wound care.
Findings
The facility failed to ensure a wound vacuum-assisted closure (wound vac) was placed properly for 1 of 3 residents reviewed for wound treatment (Resident B). The wound vac foam was found to be touching the resident's skin causing maceration, and staff education on proper placement was incomplete.
Complaint Details
Complaint IN00446310 was substantiated with federal/state deficiencies cited at F684 related to improper wound vac placement and wound care.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure a wound vacuum-assisted closure (wound vac) was placed properly for 1 of 3 residents reviewed for wound treatment (Resident B). | SS=D |
Report Facts
Census: 65
Total Capacity: 65
Medicare Census: 5
Medicaid Census: 37
Other Payor Census: 23
Wound vac pressure setting: 125
Wound vac dressing change frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sheila Huskey | Executive Director | Signed the report and was interviewed regarding wound vac supplies and staff education |
| DNS | Director of Nursing Services | Responsible for wound vac placement, re-education of nursing staff, and daily rounds to ensure proper wound vac use |
| LPN 7 | Licensed Practical Nurse | Received re-education on proper wound vac placement |
Inspection Report
Re-Inspection
Census: 53
Capacity: 80
Deficiencies: 0
Jul 18, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 05/28/24 was performed to verify compliance with fire safety and licensure requirements.
Findings
Williamsport Nursing and Rehabilitation was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility was fully sprinklered except for two detached storage garages.
Report Facts
Facility capacity: 80
Census: 53
Inspection Report
Life Safety
Census: 53
Capacity: 80
Deficiencies: 2
May 28, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 05/28/2024 to assess compliance with emergency preparedness and life safety requirements.
Findings
The facility was found in compliance with Emergency Preparedness Requirements. However, the Life Safety Code survey identified deficiencies including one resident room door that failed to close and latch properly, and a failure to conduct quarterly fire drills for one quarter in 2023.
Severity Breakdown
SS=E: 1
SS=F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| One of 35 resident room doors to the corridor failed to close completely and latch into the door frame, not resisting the passage of smoke as required by NFPA 101, 2012 edition. | SS=E |
| Facility failed to conduct quarterly fire drills for 1 of 4 quarters in 2023, affecting all staff and residents. | SS=F |
Report Facts
Deficiencies cited: 2
Residents potentially affected: 16
Fire drill quarters missed: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sheila Huskey | Executive Director | Present during observations and exit conference related to door and fire drill deficiencies |
| Maintenance Supervisor | Acknowledged door deficiency and provided information about missed fire drill | |
| Maintenance Director | Responsible for corrective actions and ongoing audits of corridor doors and fire drills |
Inspection Report
Annual Inspection
Census: 50
Capacity: 50
Deficiencies: 8
May 15, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00430614.
Findings
The facility was found deficient in multiple areas including resident dignity, care plan timing and revision, accident hazards related to hot water temperatures, catheter care, respiratory care, behavioral health services, medication administration, and food safety practices.
Complaint Details
Complaint IN00430614 was investigated with no deficiencies related to the allegations cited.
Severity Breakdown
SS=D: 5
SS=E: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to ensure residents were treated with dignity during meal assistance. | SS=D |
| Failed to ensure care plan meetings were conducted quarterly and oxygen care plans implemented. | SS=D |
| Failed to maintain hot water temperatures within safe range for residents. | SS=E |
| Failed to ensure catheter care and proper placement of catheter equipment. | SS=D |
| Failed to provide respiratory care including oxygen administration and nebulizer treatments per standards. | SS=D |
| Failed to provide necessary behavioral health services to a resident with dementia and behavioral symptoms. | SS=D |
| Medication error rate exceeded 5% due to unsafe medication administration practices and delayed meal after insulin administration. | SS=D |
| Failed to ensure proper food handling and hand sanitization during meal service. | SS=E |
Report Facts
Survey dates: 6
Census: 50
Total capacity: 50
Medication administration opportunities: 31
Medication errors observed: 2
Medication error rate: 6.45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sheila Huskey | Executive Director | Signed the report. |
| LPN 9 | Licensed Practical Nurse | Named in findings related to oxygen administration and insulin administration. |
| LPN 16 | Licensed Practical Nurse | Named in medication administration and nebulizer treatment findings. |
| CNA 7 | Certified Nurse Aide | Named in oxygen administration finding. |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple findings including dignity, care plans, oxygen administration, and medication administration. |
| Social Services Director | Social Services Director | Interviewed regarding behavioral health services and care plan meetings. |
| Administrator | Administrator | Interviewed regarding hot water temperature issues and facility policies. |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed regarding hot water temperature monitoring. |
| Dietary Manager | Dietary Manager | Interviewed regarding ice scoop and food safety practices. |
Inspection Report
Renewal
Deficiencies: 0
May 15, 2024
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on May 15, 2024.
Findings
Williamsport Nursing and Rehabilitation was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 50
Capacity: 50
Deficiencies: 0
Jan 5, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00423563.
Findings
No deficiencies related to the allegations are cited. Williamsport Nursing and Rehabilitation was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Investigation of Complaint IN00423563.
Complaint Details
Complaint IN00423563 - No deficiencies related to the allegations are cited.
Report Facts
Census: 50
Total Capacity: 50
Medicare Census: 3
Medicaid Census: 36
Other Payor Census: 11
Inspection Report
Re-Inspection
Census: 50
Capacity: 80
Deficiencies: 0
May 30, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 04/10/23 was performed to verify compliance with fire safety and licensure requirements.
Findings
Williamsport Nursing and Rehabilitation was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility was fully sprinklered except for two detached storage garages and had appropriate smoke detection systems.
Report Facts
Facility capacity: 80
Census: 50
Inspection Report
Life Safety
Census: 56
Capacity: 80
Deficiencies: 2
Apr 10, 2023
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) on 04/10/2023.
Findings
The facility was found not in compliance with Life Safety Code requirements, including failure to post a 'No Exit' sign on a non-exit door and exposed electrical wiring in the conference room. Corrective actions were planned and completed by 04/21/2023.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Court room doors with no (No Exit) sign, which could be mistaken for an exit. | SS=E |
| Exposed electrical wires in the facility conference room due to missing outlet cover. | SS=E |
Report Facts
Facility capacity: 80
Census: 56
Residents potentially affected: 14
Staff potentially affected: 2
Visitors potentially affected: 1
Residents potentially affected: 6
Staff potentially affected: 8
Visitors potentially affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sheila Huskey | Executive Director | Signed the report and participated in exit conference |
| Maintenance Director | Interviewed regarding deficiencies and corrective actions |
Inspection Report
Annual Inspection
Census: 47
Capacity: 47
Deficiencies: 10
Mar 24, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from March 20 to 24, 2023.
Findings
The facility was found deficient in multiple areas including accuracy of Minimum Data Set (MDS) assessments, development and implementation of comprehensive care plans, tube feeding management, respiratory care including nebulizer treatments, pharmacy services including medication administration and documentation, medication error rates, medication storage, and food procurement and sanitation practices.
Severity Breakdown
SS=A: 1
SS=D: 8
SS=E: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to ensure accuracy of Minimum Data Set (MDS) assessments for 2 of 17 residents reviewed. | SS=A |
| Failed to ensure a care plan was developed for a resident who had no natural teeth. | SS=D |
| Failed to ensure proper labeling of tube feeding and flush bags for 1 resident. | SS=D |
| Failed to ensure proper storage of nebulizer equipment and assessments before, during, and after nebulizer treatments for 2 residents. | SS=D |
| Failed to timely reorder and provide glaucoma eye drops for 1 resident. | SS=D |
| Failed to ensure documentation of medication administration and physician's signature on pharmacy recommendations for 3 residents. | SS=D |
| Failed to ensure documentation of medications administered for 3 residents and lacked physician rationale for 2 residents regarding unnecessary medications. | SS=D |
| Failed to ensure medication error rate was less than 5%, with 2 insulin administration errors observed during 35 opportunities. | SS=D |
| Failed to ensure medications were stored properly in medication refrigerator; temperature was 49°F with pooling water on medication bags. | SS=D |
| Failed to ensure food procurement, storage, preparation, and serving were sanitary; scoop stored in powdered thickener canister, expired food in refrigerator, improper hand hygiene and food handling observed. | SS=E |
Report Facts
Census: 47
Total Capacity: 47
Medication error rate: 5.71
Temperature: 49
Expired food date: Mar 19, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sheila Huskey | Executive Director | Signed report |
| LPN 7 | Licensed Practical Nurse | Observed insulin administration errors |
| Director of Nursing | DON | Provided interviews, policies, and explanations related to multiple deficiencies |
| Dietary Manager | DM | Provided interviews and observations related to food safety deficiencies |
| Dietary Aide 10 | DA | Observed food preparation and hand hygiene deficiencies |
| Cook 9 | Cook | Observed food preparation and hand hygiene deficiencies |
| Registered Nurse 5 | RN | Interviewed regarding insulin administration procedures |
| Social Services Director | SSD | Interviewed regarding medication regimen reviews and gradual dose reductions |
Inspection Report
Renewal
Deficiencies: 0
Mar 24, 2023
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on March 24, 2023.
Findings
Williamsport Nursing and Rehabilitation was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 48
Capacity: 48
Deficiencies: 0
Dec 20, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00395487.
Findings
The complaint IN00395487 was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00395487 was substantiated, but no deficiencies related to the allegations were cited.
Report Facts
Census SNF/NF: 48
Census Payor Type Medicare: 9
Census Payor Type Medicaid: 26
Census Payor Type Other: 13
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 0
Nov 14, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00393655.
Findings
The complaint was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00393655 was substantiated but no deficiencies related to the allegations were cited.
Report Facts
Census: 53
Census Bed Type Total: 53
Census Payor Type Total: 53
Inspection Report
Complaint Investigation
Census: 46
Capacity: 46
Deficiencies: 0
Sep 8, 2022
Visit Reason
This visit was conducted for the investigation of complaints IN00385985 and IN00386711 at Williamsport Nursing and Rehabilitation.
Findings
Complaint IN00385985 was unsubstantiated due to lack of evidence. Complaint IN00386711 was substantiated but no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00385985 was unsubstantiated due to lack of evidence. Complaint IN00386711 was substantiated but no deficiencies related to the allegations were cited.
Report Facts
Census Bed Type: 46
Census Payor Type - Medicare: 6
Census Payor Type - Medicaid: 27
Census Payor Type - Other: 13
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