Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 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.
Facility failed to document staff COVID-19 vaccination status and failed to show that staff were offered the COVID-19 vaccine or given info on where to obtain it for two staff members reviewed. The infection preventionist said staff were educated on vaccine recommendations, but the vaccine was not offered and documentation of screening, education, offering, or current vaccination status was unavailable. Two staff members reported they had not been offered the vaccine or provided info on where to get it.
A resident with a PICC line had no visible arm restriction signage, no emergency supplies in the room, and no care plan addressing the line. The facility’s policy on central venous catheters was created after surveyor questioning and did not explain how staff would be informed of limb restrictions or how immediate complications such as bleeding or line breakage would be handled; staff also confirmed the room lacked visible precautions.
Failure to obtain routine vision services for a resident with DM, HTN, and exudative age-related macular degeneration. The resident wore glasses and stated she likely needed an updated exam and did not believe she had received professional eye services in the past year. Although a physician ordered consultation with the contracted eye provider and the DON confirmed consent for vision services, the facility had no evidence that the provider had performed any eye services since admission.
A resident with a worsening heel pressure injury did not receive the ordered alternating air mattress intervention because the pump was found set to Static, and the care plan was not updated to reflect the required settings. Staff were not knowledgeable about the correct pump mode, and the assigned nurse checked only mattress inflation rather than confirming the pump was in alternating pressure mode. The resident’s heel wound became larger, painful, and infected, with cultures positive for MRSA and staphylococcus aureus.
An LPN failed to follow medication labeling and controlled substance documentation procedures during a med pass. A resident received ophthalmic drops even though the label and order did not specify which eye or eyes were to be treated, and the LPN documented the dose before the medication was actually given. The same LPN also administered Hydrocodone-APAP, clonazepam, and tramadol to three other residents without immediately recording each controlled dose on the accountability record.
Failure to provide dental services for a resident with natural teeth and reported cracked and missing teeth. The resident stated she did not believe she had received professional dental care since admission. A physician order directed staff to consult the contracted dental provider and document the results in the medical record, but the facility had no evidence that the provider had rendered dental services since admission, despite the resident’s consent for those services.
An infection control deficiency involved missed EBP use during catheter care for a resident with an indwelling urinary catheter and poor hand hygiene during a medication pass. An LPN did not wear PPE while assisting with urinary drainage, and during medication administration she removed gloves and then touched the med cart, mouse, keys, and paperwork without proper hand hygiene; she also handled the faucet with a wet hand after washing.
A resident assessed as a high fall risk was left alone in the shower without her call bell, walker, or chair alarm in place. The resident was found in the shower chair under running water after staff failed to complete the shower as planned, and she reported being cold, upset, and unable to summon help except by yelling. The DON confirmed the resident was supposed to have one person with her during showering and to have a chair alarm at all times.
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.
Failure to Document and Offer COVID-19 Vaccination to Staff
Penalty
Summary
The facility failed to maintain documentation of staff COVID-19 vaccination status and failed to provide evidence that staff were offered the COVID-19 vaccine or given information on how to obtain it for two staff members reviewed. The infection preventionist stated that staff were educated on COVID-19 vaccine recommendations, but the vaccine was not offered and no information was provided on where to get it. She also stated that she could not provide evidence of staff screening, education, vaccine offering, or current vaccination status documentation. Two staff members reported that they had not been offered the COVID-19 vaccine or given information on where to obtain it since they were hired or since the start of COVID-19.
PICC Line Care and Communication Deficiencies
Penalty
Summary
The facility failed to provide the highest practicable care for a resident with a PICC line. Resident 41 had a left arm intravenous access site covered by a dressing, but observation of the resident and his room showed no signage indicating restrictions for blood pressure checks or venipuncture on the left arm, and no emergency kit such as compression dressing supplies was visible in the room. Because of cognitive deficits, the resident could not provide information about the left arm IV site. Surveyor review also found that the resident had been scheduled for PICC insertion, then had new orders for daily IV Daptomycin and Ertapenem for 14 days, along with a daily heparin lock flush when the line was capped. Review of the resident’s plan of care did not show that staff had initiated a care plan related to the PICC line. The facility’s SNF Central Venous Catheter Policy was dated after the surveyor’s questioning and stated staff would not take blood pressure or draw blood from the affected arm, but it did not describe how all providers would be informed of limb restrictions or include immediate care for complications such as bleeding or line breakage. The facility also stated it did not have a PICC policy before the surveyor asked about it, and the Blood Pressure Measurement policy did not address the procedure for ensuring PICC-related restrictions were communicated. Staff interviews confirmed that the room lacked visible measures to prevent use of the left arm and lacked readily available emergency supplies.
Failure to Obtain Routine Vision Services
Penalty
Summary
The facility failed to obtain routine vision services for one resident who was reviewed for vision concerns. Resident 5 was observed wearing glasses and stated that she probably could use an exam to see if they needed updating, and she did not believe she had received professional eye services in the past year. Her clinical record showed that she was admitted on May 15, 2024, and had diagnoses including diabetes mellitus, hypertension, and exudative age-related macular degeneration of the left eye with active choroidal neovascularization. A physician order dated September 5, 2025, directed staff to consult the facility’s contracted provider for dental, eye, and podiatry services and to include the results of the evaluation, testing, and/or treatment in the medical record. During interview, the DON confirmed that Resident 5 consented to services from the contracted vision provider on August 27, 2025, and that she became eligible for Medicaid-provided services on September 25, 2025. The facility had no evidence that the contracted provider provided vision services since the resident’s admission to the facility.
Failure to Maintain Alternating Pressure Mattress Settings for Pressure Injury Care
Penalty
Summary
The facility failed to implement an intervention to heal a pressure injury for one resident with a left outer heel deep tissue pressure injury. Nursing documentation showed the wound measured 3.3 cm by 1.8 cm and was red, purple, boggy, and painful to touch, and the resident stated it had been painful for at least a week. The resident later had worsening wound findings, including a larger wound, an open area, surrounding redness, pain, and purulent drainage, and the wound culture was positive for MRSA. Subsequent tissue testing also identified bacteria including staphylococcus aureus, and the resident was later scheduled for PICC placement and IV antibiotics. The resident’s plan of care listed a pressure-relief mattress and removal of the bed foot board for pressure relief, but it was not updated to reflect the use of an alternating air mattress or the settings needed to ensure the mattress remained in alternating pressure mode. The physician’s order required an alternating air mattress and for staff to check inflation every shift. During observation, the Air Element pump attached to the bed showed the Static button lit, indicating the mattress was set to Static rather than alternating pressure mode. Staff interviews showed they were not knowledgeable about the correct pump settings needed to implement the alternating pressure surface. One LPN stated that if the Static button is engaged it means the mattress is not in alternating pressure mode, and the nurse assigned to the resident stated she would have to look it up. The assigned nurse also described checking inflation by pressing on the mattress surface rather than reviewing the pump settings, and the treatment record showed multiple signed checks of mattress inflation during the prior 30 days.
Medication Labeling and Controlled Substance Documentation Deficiencies
Penalty
Summary
The facility failed to ensure appropriate labeling of medication and failed to follow controlled substance accountability procedures during medication administration for four residents observed during a medication pass. The facility policy required staff to read medication labels three times before pouring medications and, for controlled medications, to immediately document the date, time, amount administered, and nurse signature on the accountability record after the medication was actually administered. During observation of medication administration, an LPN prepared Carboxymethylcellulose Sodium ophthalmic solution (Refresh Plus) for a resident with a documented diagnosis of a macula scar of the posterior pole of the right eye. The medication label and physician order did not specify which eye or eyes were to receive the drops. The LPN entered the resident’s room while the resident was in the bathroom, returned to the medication cart without administering the medication, yet documented the dose on the MAR at that time. Later, the LPN stated she administered the eye drops in both eyes and confirmed that the MAR, label, and order did not specify the eye(s) to be treated. The same LPN was observed removing controlled medications from the locked narcotic drawer for three residents: Hydrocodone-APAP 5/325 mg, Clonazepam 0.5 mg, and Tramadol HCL 50 mg. In each instance, she secured the narcotic box and left the medication cart to administer the medication, but did not record the administration on the controlled substance accountability record at the time of administration. She later confirmed the omissions during interview and updated the supply counts only at the time of the interviews.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide dental care services for one resident reviewed for dental concerns. The resident had natural teeth and told the surveyor that she had cracked her teeth, did not know how it happened, and that a couple of teeth had been pulled. She also stated that she did not believe she had received professional dental services in the facility since admission. The resident was admitted on May 15, 2024, and a physician’s order dated September 5, 2025 directed staff to consult the facility’s contracted provider for dental, eye, and podiatry services and to include the results of the evaluation, testing, and/or treatment in the medical record. During interviews, the DON and NHA were asked for evidence of professional dental care in the past year, and the DON later confirmed that the resident consented to services from the contracted provider on August 27, 2025. The resident became eligible for Medicaid-provided services on September 25, 2025, and the facility had no evidence that the contracted provider provided dental services since the resident’s admission.
Infection Control Lapses During Catheter Care and Medication Pass
Penalty
Summary
The facility failed to ensure an environment free from the potential spread of infection related to enhanced barrier precautions for a resident with an indwelling urinary catheter. Resident 1 had a physician order for Foley catheter changes every 30 days, and the facility’s care plan identified enhanced barrier precautions because of the indwelling urinary catheter. The plan noted that signage, PPE, and trash receptacles would be in the room, and that a gown and gloves would be worn for high-contact activities such as personal care and contact with the catheter. Observation showed the resident being taken into the bathroom to empty urine from the urinary collection bag, but the employee did not obtain PPE from the room organizer and later exited the bathroom without visible PPE. The employee confirmed she did not use PPE during the interaction and stated she took the resident into the bathroom to empty the urine from the collection bag. The facility also failed to ensure proper hand hygiene during medication administration for three residents. During a medication pass, an LPN donned gloves to prepare and administer medications to one resident, removed the gloves, and returned to the medication cart where she touched the cart surfaces, mouse, and keys without performing hand hygiene. The same LPN later removed gloves after administering medications to another resident, washed her hands in the staff bathroom, and then used a clean but wet hand to turn off the faucet before drying her hands. She then returned to the medication cart, donned new gloves, and continued medication administration. During the same observed medication pass, the LPN also administered medications to a third resident while wearing gloves, returned to the medication cart, used a gloved hand to write on paperwork, removed the gloves, and then used the mouse connected to the medication cart computer without performing hand hygiene. The employee confirmed that facility policy required immediate hand hygiene after glove removal and that staff were expected not to touch the faucet after washing hands without using a disposable towel. She also confirmed that she did not perform appropriate hand hygiene during the observed medication administration pass.
Failure to Maintain Fall Precautions During Shower Care
Penalty
Summary
The facility failed to ensure preventative fall interventions were implemented for one resident who had been assessed as a high fall risk. Her care plan, dated November 23, 2025, identified a potential for falls related to needing a walker to ambulate, decreased vision, and occasional incontinence, and directed that she have a chair alarm and her call bell in reach. During a reported incident on November 24, 2025, the resident was not found in her room during room rounds at change of shift, and staff later located her in the shower room under running water, shivering, and naked in a shower chair. The water temperature was documented as 96 degrees, and she was dried, dressed, and assessed with no injury or ill effects noted. Interviews and statements showed that the nurse aide who began the shower left the resident and arranged for another nurse aide to finish, but the second aide stated she could not leave her hall to do the shower. The resident stated she was left alone, became cold and upset, and had no bell to ring, so she yelled for help until another staff member came; she estimated she was in the shower for at least an hour or more. The DON confirmed the resident was supposed to have one person with her in the shower and to have a chair alarm at all times because she was a fall risk, but she was left alone in the shower with no call bell in reach, her walker was not present, and she did not have a chair alarm on.
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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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
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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 | ★★★★★ | 30 | 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 | ★★★★★ | 15 | 0 |
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