Inspection·January 6, 2025

F 0684 Nurse aide staff documented an additional three occurrences of watery stool with mucous present on [DATE], at 1:34 PM. Level of Harm - Actual harm Residents Affected - Few Review of Resident CR1's MAR indicated that licensed staff documented the administration of the Lactulose medication on [DATE], at 8:00 AM and 2:00 PM (despite Resident CR1's eight episodes of bowel incontinence on this date). A physician's progress note dated [DATE], at 6:05 PM documented that Resident CR1 was negative for constipation, diarrhea, and nausea. There was no evidence in Resident CR1's clinical record that nurse aide staff informed licensed staff of Resident CR1's numerous loose stools or that licensed staff notified the physician of this change in Resident CR1's condition. There was no evidence that licensed staff reviewed the nurse aide documentation regarding the loose stools prior to administering the lactulose. Nurse aide staff continued to document a total of seven incontinent episodes of loose stools with mucous present on [DATE], at 9:44 PM and 11:46 PM and [DATE], at 5:16 AM. Licensed staff documented the administration of the Lactulose medication on [DATE], at 8:00 PM and [DATE], at 8:00 AM, 2:00 PM, and 8:00 PM. Nurse aide staff documented a total of 11 occurrences of incontinent loose or watery stools from [DATE], at 1:34 PM, to [DATE], at 2:21 PM. Licensed staff documented the administration of the Lactulose medication three times daily from [DATE], at 8:00 AM, through [DATE], at 2:00 PM. Nursing documentation dated [DATE], at 6:15 PM revealed that Resident CR1 had increased lethargy (decrease in consciousness and altered mental abilities) and confusion. Previous assessment, resident was alert and able to answer questions. Resident CR1 had significant abdominal distention and increased swelling to her lower extremities. The documentation noted that, Resident moving bowels; however, did not note the numerous episodes of loose stools over the previous seven days. Staff contacted emergency medical services to send Resident CR1 to the hospital emergency room. A laboratory report dated [DATE], at 11:26 PM indicated Resident CR1's stool specimen was positive for C. difficile toxin (bacterial infection of the colon that produces toxins that damage the cells of the intestinal lining causing inflammation (colitis) and causes symptoms that range from diarrhea to life-threatening damage to the colon). Hospital emergency department physician documentation dated [DATE], noted that laboratory testing of Resident CR1's stool was positive for C. difficile toxin, that she had a severely elevated white blood cell count (the immune system is stimulated by conditions such as infection, inflammation, or injury), and that her abdominal CT (medical scan that uses x-rays to create images of the abdominal organs) showed extensive colitis (intestinal inflammation). The final impression documented by the provider was, C. difficile colitis. Clinical impressions included C. difficile colitis and sepsis (infection detected in the bloodstream) with acute organ dysfunction (severe injury to an organ) without septic shock (most severe stage of sepsis that often includes multiple organ failure). A history and physical assessment by the hospital physician dated [DATE], at 1:20 PM documented (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395333 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Robert Packer Hospital Skilled Care and Rehabilit 91 Hospital Drive Towanda, PA 18848 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Actual harm Resident CR1's diagnoses as toxic megacolon (serious complication of severe colitis that is characterized by a very dilated colon) secondary to C. difficile colitis and acute metabolic encephalopathy (brain dysfunction caused by an underlying condition) secondary to the previous (toxic megacolon secondary to C. difficile colitis) and decompensated cirrhosis (liver damage). Residents Affected - Few Death report documentation by the hospital physician certified that Resident CR1 died on [DATE], at 2:13 PM due to cardiopulmonary arrest (the stopping of effective breathing and blood circulation) as a consequence of septic shock because of colitis. The surveyor reviewed concerns that nurse aide staff did not inform licensed nursing staff of Resident CR1's change in condition (numerous loose stools) during interviews with the Nursing Home Administrator on [DATE], at 2:40 PM and 3:13 PM. The interview also reported the surveyor's concerns that there was no evidence that nursing staff notified Resident CR1's physician of the change in Resident CR1's condition. Interview with the Nursing Home Administrator and the Director of Nursing on [DATE], at 3:33 PM confirmed the above findings for Resident CR1. 483.25 Quality of Care Previously cited deficiency [DATE] 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395333 If continuation sheet Page 3 of 3