Inspection Reports for
Williamsport Nursing and Rehabilitation
200 SHORT ST, WILLIAMSPORT, IN, 47993
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
12.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
198% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
100% occupied
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Deficiencies: 9
Date: Jun 13, 2025
Visit Reason
Routine inspection of Williamsport Nursing and Rehabilitation to assess compliance with regulatory standards including resident care, medication management, food service, and facility sanitation.
Findings
The facility had multiple deficiencies including failure to uphold resident shower preferences, inaccurate MDS assessment coding, incomplete care plans and care plan meetings, inadequate assistance with activities of daily living, improper medication administration and disposal, failure to provide requested pain medication, improper medication labeling, food served at improper temperatures, and unsanitary kitchen conditions with incomplete cleaning logs.
Deficiencies (9)
F 0561: The facility failed to ensure a resident's shower preferences were upheld, scheduling showers twice weekly in the evening despite the resident's preference for daily morning showers.
F 0641: The facility failed to ensure accurate coding of a Minimum Data Set (MDS) assessment for a resident regarding anticoagulant medication use.
F 0657: The facility failed to develop a care plan for long-term antibiotic use and failed to hold and document quarterly care plan meetings for some residents.
F 0677: The facility failed to ensure residents received showers and shaving per their preferences, with documentation showing fewer showers administered than scheduled and residents not shaved as requested.
F 0689: The facility failed to prevent potential accidents by ensuring medications were administered and disposed of according to professional standards, including leaving medications unattended and improper disposal of refused medications.
F 0697: The facility failed to ensure a resident received requested medication for muscle spasms timely, with the nurse failing to follow up after initially withholding the medication.
F 0761: The facility failed to ensure medication was labeled properly, with an opened vial of tuberculin solution undated in the medication storage room.
F 0804: The facility failed to provide food that was palatable and served food at proper temperatures, with observations of cold food, improperly cooked items, and resident complaints about repeated menu items and cold food.
F 0812: The facility failed to maintain a sanitary kitchen environment and failed to keep cleaning logs up to date, with observations of dirty equipment, floors, and walk-in freezer, and blank cleaning logs for several months.
Report Facts
Shower administrations scheduled: 22
Shower administrations received: 10
Shower administrations received: 6
Medication orders: 12
Food temperature: 130.6
Food temperature: 113.4
Food temperature: 49.6
Food temperature: 48.4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 4 | Licensed Practical Nurse | Named in failure to follow up on resident's requested tizanidine medication |
| Director of Nursing | Director of Nursing | Provided policies and interviews regarding multiple deficiencies including medication administration, care plans, and kitchen sanitation |
| Social Service Director | Social Service Director | Interviewed regarding care plan meeting documentation and invitations |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding shaving and showering practices |
| Certified Nurse Aide 5 | Certified Nurse Aide | Interviewed regarding shaving and showering practices |
| Registered Nurse 6 | Registered Nurse | Interviewed regarding medication administration practices |
| Licensed Practical Nurse 7 | Licensed Practical Nurse | Interviewed regarding medication administration practices |
| Licensed Practical Nurse 17 | Licensed Practical Nurse | Observed medication administration and interviewed regarding medication disposal and storage |
| Dietary Manager | Dietary Manager | Interviewed regarding food service complaints, kitchen sanitation, and cleaning logs |
| Dietary Cooperate Consultant | Dietary Cooperate Consultant | Present during kitchen tour and interviewed regarding cleaning schedules |
| Dietitian Assistant | Dietitian Assistant | Provided food temperature policy |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 63
Deficiencies: 0
Date: Jun 2, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00458947.
Complaint Details
Complaint IN00458947 - No deficiencies related to the allegations are cited.
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.
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
Date: Jan 22, 2025
Visit Reason
Paper compliance review to the Investigation of Complaint IN00446310 completed on November 21, 2024.
Complaint Details
Investigation of Complaint IN00446310; paper compliance review completed and found in compliance.
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.
Report Facts
Complaint ID: 446310
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 21, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to concerns about improper placement and management of a wound vacuum-assisted closure (wound vac) for a resident with a diabetic foot ulcer.
Complaint Details
This citation relates to complaint IN00446310.
Findings
The facility failed to ensure proper placement of a wound vac for one resident, resulting in skin maceration and potential harm. The resident was discharged against medical advice after concerns about wound care and supply issues were raised.
Deficiencies (1)
F 0684: The facility failed to provide appropriate treatment and care according to orders and resident preferences by not properly placing a wound vacuum-assisted closure for one resident, causing skin maceration and potential harm.
Report Facts
Residents reviewed for wound treatment: 3
Wound vac pressure setting: 125
Wound vac dressing changes: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 7 | Licensed Practical Nurse | Re-educated by Director of Nursing Services about proper wound vac placement. |
| Director of Nursing Services | Director of Nursing Services | Placed wound vac initially and re-educated staff on proper placement. |
| Executive Director | Executive Director | Aware of resident's wife's concerns and staff education. |
| Medical Records Director | Medical Records Director | Provided information about resident's wound vac orders and supplies. |
| Admissions Director | Admissions Director | Provided facility's Skin Management Program policy. |
| MDS Coordinator | MDS Coordinator | Emphasized importance of foam not contacting skin in wound vacs. |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 65
Deficiencies: 1
Date: Nov 21, 2024
Visit Reason
This visit was for the investigation of Complaint IN00446310 related to federal/state deficiencies concerning wound care.
Complaint Details
Complaint IN00446310 was substantiated with federal/state deficiencies cited at F684 related to improper wound vac placement and 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.
Deficiencies (1)
Failed to ensure a wound vacuum-assisted closure (wound vac) was placed properly for 1 of 3 residents reviewed for wound treatment (Resident B).
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
Date: 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
Date: 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.
Deficiencies (2)
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.
Facility failed to conduct quarterly fire drills for 1 of 4 quarters in 2023, affecting all staff and residents.
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
Routine
Deficiencies: 8
Date: May 15, 2024
Visit Reason
Routine inspection of Williamsport Nursing and Rehabilitation to assess compliance with regulatory standards including resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including resident dignity, care planning, hot water temperature safety, catheter care, respiratory services, behavioral health services, medication administration, and food handling practices. Several residents were affected with minimal harm or potential for harm.
Deficiencies (8)
F 0550: The facility failed to ensure residents were treated with dignity during eating assistance for 1 of 1 resident reviewed (Resident 4). The Speech Language Pathologist stood while assisting instead of sitting.
F 0657: The facility failed to conduct quarterly care plan meetings for 1 of 3 residents (Resident 7) and failed to implement an oxygen care plan for 1 of 3 residents (Resident 15).
F 0689: The facility failed to maintain safe hot water temperatures, exposing 5 of 7 residents to water temperatures exceeding 120°F, risking burns.
F 0690: The facility failed to ensure proper catheter care for 1 of 1 resident (Resident 15), with catheter bag touching the floor and improper placement.
F 0695: The facility failed to provide appropriate respiratory care for 2 of 2 residents (Residents 15 and 8), including incorrect oxygen settings and failure to assess after nebulizer treatments.
F 0740: The facility failed to provide necessary behavioral health services to 1 of 4 residents reviewed (Resident 48), including lack of psychiatric consultation and family involvement.
F 0759: The facility failed to maintain medication error rates below 5%, with 2 errors in 31 opportunities (6.45%), including touching medication capsules with bare hands and delayed meal after insulin administration.
F 0812: The facility failed to ensure proper food handling and hand hygiene during meal service, including improper ice scoop storage and failure of staff to sanitize hands between assisting residents.
Report Facts
Deficiencies cited: 8
Medication error rate: 6.45
Water temperature: 134.4
Oxygen flow rate: 3
Insulin units: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Provided interviews and facility policies related to dignity, care planning, respiratory care, and medication administration. | |
| Speech Language Pathologist | Observed assisting Resident 4 with eating while standing. | |
| Licensed Practical Nurse (LPN) 9 | Involved in oxygen administration and medication administration observations. | |
| Certified Nurse Aide (CNA) 3 | Observed failing to sanitize hands between assisting residents during meal service. | |
| Maintenance Supervisor | Interviewed regarding hot water temperature monitoring and maintenance. |
Inspection Report
Annual Inspection
Census: 50
Capacity: 50
Deficiencies: 8
Date: May 15, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00430614.
Complaint Details
Complaint IN00430614 was investigated with no deficiencies related to the allegations cited.
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.
Deficiencies (8)
Failed to ensure residents were treated with dignity during meal assistance.
Failed to ensure care plan meetings were conducted quarterly and oxygen care plans implemented.
Failed to maintain hot water temperatures within safe range for residents.
Failed to ensure catheter care and proper placement of catheter equipment.
Failed to provide respiratory care including oxygen administration and nebulizer treatments per standards.
Failed to provide necessary behavioral health services to a resident with dementia and behavioral symptoms.
Medication error rate exceeded 5% due to unsafe medication administration practices and delayed meal after insulin administration.
Failed to ensure proper food handling and hand sanitization during meal service.
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
Date: 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
Date: Jan 5, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00423563.
Complaint Details
Complaint IN00423563 - No deficiencies related to the allegations are cited.
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.
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
Date: 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
Date: 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.
Deficiencies (2)
Court room doors with no (No Exit) sign, which could be mistaken for an exit.
Exposed electrical wires in the facility conference room due to missing outlet cover.
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
Routine
Deficiencies: 9
Date: Mar 24, 2023
Visit Reason
Routine inspection of Williamsport Nursing and Rehabilitation to assess compliance with healthcare regulations and standards.
Findings
The facility had multiple deficiencies including failure to develop accurate care plans, improper labeling and storage of feeding tube bags, inadequate respiratory care documentation, medication administration and documentation errors, improper medication storage, and food safety violations in the kitchen.
Deficiencies (9)
F 0656: The facility failed to develop and implement a complete care plan reflecting a resident's edentulous status, resulting in an inaccurate care plan for Resident 31.
F 0693: The facility failed to ensure proper labeling of tube feeding and flush bags for Resident 32, lacking date, time, and initials on multiple observations.
F 0695: The facility failed to provide safe respiratory care by not properly storing nebulizer equipment and not documenting assessments before, during, and after nebulizer treatments for Residents 31 and 32.
F 0755: The facility failed to timely reorder and provide glaucoma eye drops for Resident 32, resulting in missed medication doses.
F 0757: The facility failed to ensure documentation of medication administration for Residents 17, 40, and 26, and lacked physician signatures on pharmacy recommendations for Resident 40.
F 0758: The facility failed to implement gradual dose reductions and document rationale for psychotropic medications for Residents 17 and 40.
F 0759: The facility failed to maintain medication error rates below 5%, with improper insulin administration techniques observed for Residents 19 and 27.
F 0761: The facility failed to ensure medications were stored properly in the 200 hallway medication refrigerator, with temperatures above recommended levels and water pooling on medication bags.
F 0812: The facility failed to ensure food safety practices in the kitchen, including improper storage of scoops, expired food, unsanitary food preparation, and inadequate hand hygiene by staff.
Report Facts
Medication error rate: 5.71
Temperature range: 49
Temperature range: 32
Temperature range: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Provided policy documents and interviews related to care plan, medication, and respiratory care deficiencies |
| RN 5 | Registered Nurse | Interviewed regarding tube feeding bag labeling and insulin administration procedures |
| LPN 6 | Licensed Practical Nurse | Observed medication refrigerator temperature and storage |
| LPN 7 | Licensed Practical Nurse | Observed medication refrigerator temperature and insulin administration |
| Dietary Manager | Dietary Manager | Interviewed regarding kitchen food safety and hand hygiene practices |
| Dietary Aide 10 | Dietary Aide | Observed preparing pureed foods and hand hygiene practices |
| Cook 9 | Cook | Observed food plating and hand hygiene practices |
Inspection Report
Annual Inspection
Census: 47
Capacity: 47
Deficiencies: 10
Date: 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.
Deficiencies (10)
Failed to ensure accuracy of Minimum Data Set (MDS) assessments for 2 of 17 residents reviewed.
Failed to ensure a care plan was developed for a resident who had no natural teeth.
Failed to ensure proper labeling of tube feeding and flush bags for 1 resident.
Failed to ensure proper storage of nebulizer equipment and assessments before, during, and after nebulizer treatments for 2 residents.
Failed to timely reorder and provide glaucoma eye drops for 1 resident.
Failed to ensure documentation of medication administration and physician's signature on pharmacy recommendations for 3 residents.
Failed to ensure documentation of medications administered for 3 residents and lacked physician rationale for 2 residents regarding unnecessary medications.
Failed to ensure medication error rate was less than 5%, with 2 insulin administration errors observed during 35 opportunities.
Failed to ensure medications were stored properly in medication refrigerator; temperature was 49°F with pooling water on medication bags.
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.
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
Date: 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
Date: Dec 20, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00395487.
Complaint Details
Complaint IN00395487 was substantiated, but no deficiencies related to the allegations were cited.
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.
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
Date: Nov 14, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00393655.
Complaint Details
Complaint IN00393655 was substantiated but no deficiencies related to the allegations were cited.
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.
Report Facts
Census: 53
Census Bed Type Total: 53
Census Payor Type Total: 53
Inspection Report
Complaint Investigation
Census: 46
Capacity: 46
Deficiencies: 0
Date: Sep 8, 2022
Visit Reason
This visit was conducted for the investigation of complaints IN00385985 and IN00386711 at Williamsport Nursing and Rehabilitation.
Complaint Details
Complaint IN00385985 was unsubstantiated due to lack of evidence. Complaint IN00386711 was substantiated but no deficiencies related to the allegations were cited.
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.
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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