Pennsylvania Department of Health
 KITTANNING HEALTH & REHAB CENTER
Patient Care Inspection Results

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KITTANNING HEALTH & REHAB CENTER
Inspection Results For:

There are  137 surveys for this facility. Please select a date to view the survey results.

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KITTANNING HEALTH & REHAB CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Survey in response to two complaints, completed on April 29, 2025, it was determined that Kittanning Health & Rehab Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in §483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

§483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).
Observations:

Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to ensure the physician was appropriately notified of missed medication doses for one of five residents reviewed (Resident R1).

Findings include:

Review of facility policy "Medication Shortages/Unavailable Medications" dated 1/12/25, indicated upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from pharmacy. If the medication is unavailable from pharmacy or a third-party pharmacy, and cannot be supplied from the manufacturer, facility should obtain alternate physician/prescriber orders, as necessary.

Review of facility policy "Resident Change in Condition" dated 1/12/25, indicated the physician/provider and resident/family/responsible party will be notified when there has been a need to alter the resident's medical treatment, including a change in provider orders.

Review of the clinical record indicated Resident R1 was admitted to the facility on 9/5/23.

Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/19/25, indicated diagnoses of high blood pressure, depression, and personal history of malignant neoplasm of prostate (prostate cancer).

Review of a physician order dated 3/11/25, indicated to administer Nubeqa (a medication given to decrease growth and spread of prostate cancer) 600 milligrams by mouth twice a day.

Review of Resident R1's April 2025 Medication Administration Record revealed the scheduled medication was not administered on the following:
- 4/21/25 PM Med Pass, the documented reason was "Drug/Item Unavailable: medication was reordered has not arrived"
- 4/22/25 AM Med Pass, the documented reason was "Not Administered: Refused"
- 4/22/25 PM Med Pass, the documented reason was "Drug/Item Unavailable: family is to provide"
- 4/23/25 AM Med Pass, the documented reason was "Drug/Item Unavailable"
- 4/23/25 PM Med Pass, the documented reason was "Drug/Item Unavailable"
- 4/24/25 AM Med Pass, the documented reason was "Drug/Item Unavailable"
- 4/24/25 PM Med Pass, the documented reason was "Drug/Item Unavailable: family to supply"
- 4/25/25 AM Med Pass, the documented reason was "Drug/Item Unavailable"
- 4/25/25 PM Med Pass, the documented reason was "Drug/Item Unavailable"
- 4/26/25 AM Med Pass, the documented reason was "Drug/Item Unavailable"
- 4/26/25 PM Med Pass, the documented reason was "Drug/Item Unavailable"
- 4/27/25 AM Med Pass, the documented reason was "Drug/Item Unavailable"
- 4/27/25 PM Med Pass, the documented reason was "Drug/Item Unavailable"
- 4/28/25 AM Med Pass, the documented reason was "Drug/Item Unavailable"
- 4/28/25 PM Med Pass, the documented reason was "Drug/Item Unavailable"
- 4/29/25 AM Med Pass, the documented reason was "Drug/Item Unavailable: supplied by family; awaiting arrival"

During an interview on 4/29/25, at 9:56 a.m. the Director of Nursing (DON) stated, "Resident R1 was admitted in 2023 on this cancer medication. He's his own person, but he has a brother involved. This cancer medication is $1500 a month, his brother pays out of pocket for it. We recently found out that this brother is now unable to order and provide the medication. He got it from a pharmacy in Delaware. He has another brother who is willing to take over and supply the medication, however since Resident R1 is his own person and responsible party, we can't give the other brother any of his medication information without his permission and Resident R1 has stated he doesn't want us to talk to his brother."

During an interview on 4/29/25, at 10:41 a.m. the DON stated the facility was unable to provide documentation that the physician was made aware of Resident R1's medication being unavailable and that the facility failed to ensure the physician was appropriately notified of missed medication doses for Resident R1.

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18 (b)(1) Management.
28 Pa. Code: 211.10 (c)(d) Resident Care policies.
28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services.



 Plan of Correction - To be completed: 05/15/2025

F580

1) R1's Physician was notified of the omitted medication
From 4/21, 4/22, 4/23, 4/24, 4/25, 4/26, 4/27, 4/28 and 4/29/25.
R1 has resumed the omitted medication on 4/30/25.
2) Facility audit of medication carts was completed to ensure
no other residents have omitted medications requiring
MD notification.
3) DON/Designee to educate nurses on "Medication shortages/Unavailable
Medications" policy and "Resident change of condition
Policy" by 15MAY2025
4) DON/Designee will conduct audit "Administration compliance
Report" 3x week x 4 weeks then monthly x 2 for omitted medication
To ensure notification of change in condition related to
Medication unavailable.
5) The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendation

483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on a review of facility policy, clinical record, and staff interview, it was determined that the facility failed to provide medications as ordered by the physician for one of five residents (Resident R1).

Findings include:

Review of facility policy "Medication Shortages/Unavailable Medications" dated 1/12/25, indicated upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from pharmacy. If the medication is unavailable from pharmacy or a third-party pharmacy, and cannot be supplied from the manufacturer, facility should obtain alternate physician/prescriber orders, as necessary.

Review of the clinical record indicated Resident R1 was admitted to the facility on 9/5/23.

Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/19/25, indicated diagnoses of high blood pressure, depression, and personal history of malignant neoplasm of prostate (prostate cancer).

Review of a physician order dated 3/11/25, indicated to administer Nubeqa (a medication given to decrease growth and spread of prostate cancer) 600 milligrams by mouth twice a day.

Review of Resident R1's April 2025 Medication Administration Record revealed the scheduled medication was not administered on the following:
- 4/21/25 PM Med Pass, the documented reason was "Drug/Item Unavailable: medication was reordered has not arrived"
- 4/22/25 AM Med Pass, the documented reason was "Not Administered: Refused"
- 4/22/25 PM Med Pass, the documented reason was "Drug/Item Unavailable: family is to provide"
- 4/23/25 AM Med Pass, the documented reason was "Drug/Item Unavailable"
- 4/23/25 PM Med Pass, the documented reason was "Drug/Item Unavailable"
- 4/24/25 AM Med Pass, the documented reason was "Drug/Item Unavailable"
- 4/24/25 PM Med Pass, the documented reason was "Drug/Item Unavailable: family to supply"
- 4/25/25 AM Med Pass, the documented reason was "Drug/Item Unavailable"
- 4/25/25 PM Med Pass, the documented reason was "Drug/Item Unavailable"
- 4/26/25 AM Med Pass, the documented reason was "Drug/Item Unavailable"
- 4/26/25 PM Med Pass, the documented reason was "Drug/Item Unavailable"
- 4/27/25 AM Med Pass, the documented reason was "Drug/Item Unavailable"
- 4/27/25 PM Med Pass, the documented reason was "Drug/Item Unavailable"
- 4/28/25 AM Med Pass, the documented reason was "Drug/Item Unavailable"
- 4/28/25 PM Med Pass, the documented reason was "Drug/Item Unavailable"
- 4/29/25 AM Med Pass, the documented reason was "Drug/Item Unavailable: supplied by family; awaiting arrival"

During an interview on 4/29/25, at 9:56 a.m. the Director of Nursing (DON) stated, "Resident R1 was admitted in 2023 on this cancer medication. He's his own person, but he has a brother involved. This cancer medication is $1500 a month, his brother pays out of pocket for it. There was an agreement with previous management and the brother when Resident R1 was admitted. We recently found out that this brother is now unable to order and provide the medication. He got it from a pharmacy in Delaware. He has another brother who is willing to take over and supply the medication, however since Resident R1 is his own person and responsible party, we can't give the other brother any of his medication information without his permission and Resident R1 has stated he doesn't want us to talk to his brother."

During an interview on 4/29/25, at 11:19 a.m. the DON stated, "We just had another meeting with Resident R1 and he is refusing to allow us to speak to his brother regarding his care. We can get his medication through our pharmacy, however he refused to give us an answer regarding how he wants the facility to proceed with obtaining his medication, he just screams at staff."

During an interview on 4/29/25, at 2:43 p.m. the DON confirmed that the facility failed to provide medications as ordered by the physician for Resident R1.

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18 (b)(1) Management.
28 Pa. Code: 211.10 (c)(d) Resident Care policies.
28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services.



 Plan of Correction - To be completed: 05/15/2025

F684
1) R1 has resumed the omitted medication on 4/30/25
2) DON/designee to audit all residents to ensure medication prescribed is available from pharmacy on 06MAY2025.
3) DON/Designee to educate nurses on policy for "Medication shortages/unavailable medications" by 15MAY2025
4) DON/Designee will conduct "Medication compliance report" audits
3x per week for 4 weeks then monthly x2 months to ensure residents
have medications available.
5) The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendation.

483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
The facility must ensure that its-
§483.45(f)(2) Residents are free of any significant medication errors.
Observations:

Based on review of facility policy, clinical record review, and interviews with staff, it was determined that the facility failed to ensure that residents are free of significant medication errors for one of five residents reviewed (Resident R1).

Findings include:

Review of facility policy "Medication Shortages/Unavailable Medications" dated 1/12/25, indicated upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from pharmacy. If the medication is unavailable from pharmacy or a third-party pharmacy, and cannot be supplied from the manufacturer, facility should obtain alternate physician/prescriber orders, as necessary.

Review of the clinical record indicated Resident R1 was admitted to the facility on 9/5/23.

Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/19/25, indicated diagnoses of high blood pressure, depression, and personal history of malignant neoplasm of prostate (prostate cancer).

Review of a physician order dated 3/11/25, indicated to administer Nubeqa (a medication given to decrease growth and spread of prostate cancer) 600 milligrams by mouth twice a day.

Review of Resident R1's April 2025 Medication Administration Record revealed the scheduled medication was not administered on the following:
- 4/21/25 PM Med Pass, the documented reason was "Drug/Item Unavailable: medication was reordered has not arrived"
- 4/22/25 AM Med Pass, the documented reason was "Not Administered: Refused"
- 4/22/25 PM Med Pass, the documented reason was "Drug/Item Unavailable: family is to provide"
- 4/23/25 AM Med Pass, the documented reason was "Drug/Item Unavailable"
- 4/23/25 PM Med Pass, the documented reason was "Drug/Item Unavailable"
- 4/24/25 AM Med Pass, the documented reason was "Drug/Item Unavailable"
- 4/24/25 PM Med Pass, the documented reason was "Drug/Item Unavailable: family to supply"
- 4/25/25 AM Med Pass, the documented reason was "Drug/Item Unavailable"
- 4/25/25 PM Med Pass, the documented reason was "Drug/Item Unavailable"
- 4/26/25 AM Med Pass, the documented reason was "Drug/Item Unavailable"
- 4/26/25 PM Med Pass, the documented reason was "Drug/Item Unavailable"
- 4/27/25 AM Med Pass, the documented reason was "Drug/Item Unavailable"
- 4/27/25 PM Med Pass, the documented reason was "Drug/Item Unavailable"
- 4/28/25 AM Med Pass, the documented reason was "Drug/Item Unavailable"
- 4/28/25 PM Med Pass, the documented reason was "Drug/Item Unavailable"
- 4/29/25 AM Med Pass, the documented reason was "Drug/Item Unavailable: supplied by family; awaiting arrival"

During an interview on 4/29/25, at 9:56 a.m. the Director of Nursing (DON) stated, "Resident R1 was admitted in 2023 on this cancer medication. He's his own person, but he has a brother involved. This cancer medication is $1500 a month, his brother pays out of pocket for it. We recently found out that this brother is now unable to order and provide the medication. He got it from a pharmacy in Delaware. He has another brother who is willing to take over and supply the medication, however since Resident R1 is his own person and responsible party, we can't give the other brother any of his medication information without his permission and Resident R1 has stated he doesn't want us to talk to his brother."

During an interview on 4/29/25, at 11:19 a.m. the DON stated, "We just had another meeting with Resident R1 and he is refusing to allow us to speak to his brother regarding his care. We can get his medication through our pharmacy, however he refused to give us an answer regarding how he wants the facility to proceed with obtaining his medication, he just screams at staff."

During an interview on 4/29/25, at 2:43 p.m. the DON confirmed that the facility failed to ensure that residents are free of significant medication errors for one of five residents reviewed (Resident R1) as required.

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18 (b)(1) Management.
28 Pa. Code: 211.10 (c)(d) Resident Care policies.
28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services.



 Plan of Correction - To be completed: 05/15/2025

F760

1) R1 has resumed his omitted medication on 4/30/25
Physician, and resident was made aware of the medication error.
2) DON/designee to audit medication carts to ensure all medication are available by 06MAY2025.
3) DON/designee to educate nurses on "Medication shortages/Unavailable Medications" policy by 15MAY2025
4) DON/Designee will conduct "Medication compliance report"
audits 3x per week for 4 weeks then monthly x2 months to ensure residents
have medications available.
5) The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendation.








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