F 0744
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Level of Harm - Minimal harm
or potential for actual harm
Based on clinical record review and staff interview, it was determined that the facility failed to develop and
implement an individualized person-centered care plan to address dementia and cognitive loss displayed
by one of three residents reviewed (Resident 61).
Residents Affected - Few
Findings include:
Clinical record review for Resident 61 revealed the facility admitted her on January 2, 2025, with diagnosis
of Dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily
life). A review of Resident 61's admission Minimum Data Set Assessment (MDS, a form completed at
specific intervals to determine care needs) dated January 8, 2025, indicated that the facility assessed
Resident 61 as having a diagnosis of dementia. The facility determined that a care plan for dementia and
cognitive loss would be developed.
A review of Resident 61's care plan entitled, psychosocial needs initiated January 4, 2025, revealed that
there was no indication that the facility had developed and implemented a person-centered care plan to
address the resident's dementia and cognitive loss. Resident 61's clinical record also had a care plan
entitled, Anxiety-Cognitive, initiated on January10, 2025, that failed to address individualized
person-centered approaches to address Resident 61's dementia and cognitive loss.
The findings were reviewed with the Nursing Home Administrator on February 12, 2025, at 12:10 PM and
she confirmed that Resident 61 did not have an individualized care plan for dementia and cognitive loss.
483.40(b)(3) Dementia Treatment and Services
Previously cited 3/8/2024
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
395333
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
02/12/2025
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation and staff interview, it was determined that the facility failed to store food and maintain
food service equipment in accordance with professional standards for food service safety in the facility's
main kitchen.
Findings include:
Observation of the facility's main kitchen on February 9, 2025, at 10:15 AM with Employee 1, dietary
supervisor, revealed the following:
The lower shelf of the food preparation table beside the steamer was observed with a large clear plastic
container with a white powdery substance filling half of the container. The exterior of the contained had
dried food on it, was dusty, and sticky to touch. The container was labeled with a sticker indicating flour was
in the bin, and dated August 4, 2024, with a use by date of January 4, 2025.
An additional large clear plastic container beside the flour also with a dirty exterior on the sides and lid of
the container with dried food, and dust, partially filled with rice labeled with a May 21, 2024, as to when it
was placed in the bin, with a use by date of November 4, 2024.
The exterior side of the steamer was observed with dried food splatter.
A white plastic pipe extending from behind the ice machine along the wall behind a preparation table was
dirty and dusty and dried food debris was observed collected between the pipe and the wall.
The open area behind the steamers, oven, and stove, was observed with dust and debris buildup.
A large metal rack was observed hanging from the ceiling over a food preparation table. Multiple pans,
ladles, spoons and whisks were observed hanging from the rack with food contact surfaces stored open to
air, with no cover. The ceiling tiles directly above the rack contained dried food splatter.
The exterior base of the food warmer contained a buildup of dried food particles and dust.
Two white potholders were observed on a preparation table significantly stained and blackened.
A small upright cooler by the food service tray line contained dried food and liquid on the exterior.
The lower shelves in the walk-in cooler were soiled with debris and dried food and liquid spots.
Review of the main kitchen's temperature monitoring log for the walk-in freezer, walk-in cooler salad
refrigerator, line refrigerator, cooks' refrigerator, and juice refrigerator, revealed no documented temperature
monitoring for February 6, 7, 8, or as of the time of observation on February 9, 2025. The last documented
temperatures for the items were listed as February 5, 2025.
The above information was reviewed with the Nursing Home Administrator and Director of Nursing on
(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
02/12/2025
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 0812
February 11, 2025, at 2:10 PM.
Level of Harm - Minimal harm
or potential for actual harm
28 Pa. Code 201.14 (a) Responsibility of Licensee
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395333
If continuation sheet
Page 3 of 3
