Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Robert Packer Hospital Skilled Care And Rehabilit during CMS and state inspections, most recent first.
The facility failed to maintain food storage and service equipment according to professional standards. Observations revealed dirty and expired food containers, unclean equipment, and missing temperature logs for several days. The kitchen had dust and debris buildup, and food contact surfaces were improperly stored.
A resident with dementia did not receive an individualized care plan to address their cognitive loss. Despite being assessed with dementia, the facility's existing care plans did not include person-centered approaches for managing the condition. This deficiency was confirmed by the Nursing Home Administrator and had been previously cited.
A resident experienced a change in condition with multiple episodes of loose stools, but the facility failed to communicate this to the physician or adjust medication administration. Despite documentation of loose stools, Lactulose was administered as scheduled, leading to the resident's hospitalization and death from C. difficile colitis and sepsis.
Food Storage and Equipment Maintenance Deficiencies
Penalty
Summary
The facility failed to store food and maintain food service equipment in accordance with professional standards for food service safety in the main kitchen. During an observation, a large clear plastic container labeled as flour was found with a dirty exterior, sticky to touch, and dated beyond its use-by date. Another container with rice was similarly dirty and past its use-by date. The exterior of the steamer had dried food splatter, and a white plastic pipe behind the ice machine was dirty and dusty with dried food debris. The open area behind the steamers, oven, and stove had dust and debris buildup. Additionally, a metal rack hanging from the ceiling over a food preparation table had multiple pans, ladles, spoons, and whisks stored open to air, with no cover, and the ceiling tiles above had dried food splatter. The base of the food warmer had a buildup of dried food particles and dust, and two potholders were significantly stained and blackened. A small upright cooler had dried food and liquid on its exterior, and the lower shelves in the walk-in cooler were soiled with debris and dried food and liquid spots. The temperature monitoring log for various refrigerators showed no documented temperatures for several days leading up to the observation.
Plan Of Correction
Contents discarded out of the large clear plastic container with flour. The container was then cleaned, refilled with appropriate labels. An additional large clear plastic container (rice) contents discarded, container has been cleaned and labeled appropriately. The exterior side of the steamer has been cleaned. A white plastic pipe extending from behind the ice machine and along the wall behind a preparation table has been cleaned. The open area behind the steamers, oven, and stove has been cleaned. A large metal rack hanging from the ceiling over a food preparation table with multiple pans, ladles, spoons, and whisks has been removed and ceiling tiles replaced. The exterior base of the food warmer has been cleaned. Two white potholders observed on a preparation table have been thrown out. A small upright cooler by the food service tray line has been cleaned. The lower shelves in the walk-in cooler have been cleaned. The main kitchen's temperature monitoring log for the walk-in freezer, walk-in cooler, salad refrigerator, line refrigerator, cooks' refrigerator, and the juice refrigerator has been moved to a binder and checked 2 times daily. Education provided to dietary staff and managers on kitchen cleanliness, appropriate labeling, and temperature logs. Kitchen audits for cleanliness and appropriate labels to be completed weekly x 4 weeks, then monthly x 5. Kitchen temperature log audits to be completed weekly x 4, then monthly x 5. The dietary manager will continue to reinforce kitchen cleanliness, temperature documentation, and appropriate labeling. The dietary manager will review any issues of noncompliance with staff involved. Any trends identified will be addressed with staff per the progressive disciplinary process as appropriate. Audits will continue to be reported by the Dietary Manager at scheduled Quality Assurance Performance Improvement meetings monthly.
Failure to Implement Individualized Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized person-centered care plan for a resident diagnosed with dementia. The resident, admitted on January 2, 2025, was assessed with dementia as per the Minimum Data Set Assessment conducted on January 8, 2025. Despite this assessment, the facility did not create a specific care plan addressing the resident's dementia and cognitive loss. Instead, the existing care plans titled 'psychosocial needs' and 'Anxiety-Cognitive' did not include individualized approaches to manage the resident's condition. The deficiency was confirmed during a review with the Nursing Home Administrator on February 12, 2025, who acknowledged the absence of a tailored care plan for the resident's dementia and cognitive loss. This oversight was noted as a repeat deficiency, having been previously cited on March 8, 2024.
Plan Of Correction
Resident 61 care plan revised to a person-centered care plan to address the resident's dementia and cognitive loss. Full house audit of all residents with a diagnosis of dementia and associated care plan to determine any other resident that may be affected. Education provided to Nursing staff on person-centered dementia care plans and interventions. Care plan audits to be completed weekly x 4 weeks, then monthly x 6 by the Skilled Nursing Director of Nursing. The Director of Nursing will continue to reinforce the importance of implementing person-centered care plans specifically for residents with dementia. The Director of Nursing will review any non-compliant findings with the staff involved. Any trends identified will be addressed with the staff per the progressive disciplinary process if appropriate. Audits will continue to be reported by the Skilled Nursing DON at scheduled Quality Assurance Performance Improvement meetings monthly.
Failure to Communicate Change in Condition Leads to Resident's Death
Penalty
Summary
The facility failed to provide the highest practicable care for a resident, identified as Resident CR1, who experienced a change in condition that led to hospitalization and death. The resident was admitted with a physician's order to receive Lactulose three times a day, with instructions to hold the medication for loose stools. Despite documentation of multiple episodes of loose stools, the medication was administered as scheduled without adjustment or notification to the physician. Nurse aide staff documented numerous occurrences of loose stools over several days, but there was no evidence that this information was communicated to licensed nursing staff or that the physician was informed of the resident's condition. The medication administration record showed that Lactulose was given consistently, even as the resident's condition worsened, with increased lethargy, confusion, and abdominal distention noted before the resident was sent to the hospital. Upon hospitalization, the resident was diagnosed with C. difficile colitis, sepsis, and toxic megacolon, which ultimately led to her death. The surveyor's review highlighted the lack of communication between nurse aide staff and licensed staff, as well as the failure to notify the physician of the resident's significant change in condition, contributing to the adverse outcome.
Plan Of Correction
Action Steps: 1. The Robert Packer Hospital (RPH) Skilled Nursing Unit Administrator is responsible for this action plan. 2. The Director of Nursing for the Skilled Nursing Unit completed audits of current residents for physician-ordered Lactulose and parameters. 3. The Director of Nursing for the Skilled Nursing Unit completed an audit of current residents to determine any other residents that might be affected. The audit of current residents included the number of stool occurrences and consistency; no other residents were affected. 4. Updated Change in resident condition policy to include the suggestion of notification to the physician of 2 or more loose/watery stools within 12 hours was completed and approved. 5. Weekly BM paper tool utilized in addition to EMR for tracking started on 1/15/2025. 6. Additional electronic report created to assist with monitoring bowel consistency and occurrence daily on 1/14/2025. 7. Education to all nursing staff provided on reporting a change in condition including a change in bowel consistency completed 01/17/2025. 8. All nursing staff education provided on the requirement to follow physicians' orders completed 01/17/2025. 9. The Director of Nursing will continue to audit resident medical records for bowel consistency and occurrences and that appropriate notification to the physician is documented. 10. The Director of Nursing will continue to reinforce the importance of following orders related to the administration of Lactulose with all nursing staff during staff meetings and daily huddles. 11. The Director of Nursing will review any non-compliant findings with the staff involved. Any trends identified will be addressed with the staff per the progressive disciplinary process if appropriate. 12. Audits will continue to be reported by the Skilled Nursing DON at scheduled Quality Assurance Performance Improvement meetings weekly for 12 weeks, then monthly for 9 months. 13. The Administrator of the Skilled Nursing Unit will continue to report audit compliance quarterly to the RPH Patient Safety and Quality committee. 14. Directed in-service is scheduled for 01/21/2025 through PADONA.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Towanda
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Athens Nursing And Rehabilitation Center | 13.2 mi | — | 0 | 0 |
| Sayre Health Care Center | 15.5 mi | — | 19 | 0 |
| Elderwood At Waverly | 16.2 mi | — | 2 | 1 |
| Darway Healthcare And Rehabilitation Center | 20.9 mi | — | 6 | 0 |
| Bradford Hills Nursing & Rehabilitation Center | 24.1 mi | — | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.