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 Kittanning Health & Rehab Center during CMS and state inspections, most recent first.
A facility failed to ensure residents were free from significant med errors. One resident with HTN, DM, and pain received an unapproved opioid in addition to scheduled Percocet, became unresponsive, and required Narcan after staff discovered the error. Another resident with DM did not receive ordered insulin during a med pass, and the LPN confirmed the insulin was not administered as ordered.
Insufficient nursing staffing led to missed and delayed resident care for multiple residents. PBJ data showed a one-star staffing rating with excessively low weekend staffing, and residents reported not always receiving scheduled showers because enough staff were not available. An LPN and a nurse aide confirmed the shortage, describing bad staffing on the 3 to 11 shift, skipped showers, difficulty with Hoyer lifts, and delays with routine care; the DON also confirmed the facility did not have sufficient nursing staff for the identified residents.
Emergency equipment was not kept in safe operating condition for crash carts in the Common Room and Memory Impaired Unit, and for AEDs in the Common Room and Main Dining Room. The Common Room crash cart checklist had missing signatures, AED battery checks were not documented, and observation found expired suction tubing plus an opened Ambu bag with an old package date. The Memory Impaired Unit crash cart also contained expired IV tubing, IV start kits, and suction tubing, which were confirmed by an RN, an LPN, and the DON.
The facility failed to ensure staff were fit tested for NIOSH-approved N-95 respirators while caring for residents with suspected or confirmed COVID during an outbreak. The IP confirmed no staff had been fit tested, and an RN, LPN, and nurse aide each said they had not been fit tested despite entering COVID rooms. The facility also failed to monitor the temperature of a resident’s personal refrigerator, with missing or absent logs across multiple months.
Failure to provide quarterly resident trust fund statements for four residents with active resident fund accounts. During a resident council interview, several residents stated they had not received statements, and record review found no evidence that the statements were sent. The BOM confirmed the facility could not provide proof of mailing the required quarterly statements.
The facility failed to convey resident funds and close trust accounts within 30 days for three closed residents. One resident had dementia, depression, anxiety, and restlessness and expired; another had dementia, HTN, and Takotsubo syndrome and was found with no audible pulse; a third had lumbar fracture, HTN, and chronic pain and was sent to the hospital after a head injury. The trust fund statement showed remaining balances for all three residents, and the BOM confirmed the accounts were not closed timely.
Inadequate respiratory care was identified for three residents receiving oxygen therapy, and one also had PRN nebulizer treatment ordered. Observations found oxygen tubing and humidification equipment that were undated or improperly maintained, and nebulizer tubing that was not stored in a bag when not in use. An LPN stated tubing should be changed weekly and dated, and the DON confirmed the deficiency.
Missing Physician Responses for MRRs: The facility failed to ensure physician response and completion of monthly MRRs for four sampled residents. Records showed repeated missing physician completion for residents with diagnoses including HTN, bipolar disorder, dementia, HF, DM, anxiety, Parkinson's disease, and depression. One resident's MRR identified prolonged Phenazopyridine use and recommended discontinuation, but no physician response was documented.
Missing Required Annual Staff Training: The facility failed to maintain an effective staff training program after review of personnel files showed missing annual in-service education for an LPN, a nurse aide, and another LPN. Required topics such as Effective Communication, Resident Rights, Abuse, Infection Control, Compliance and Ethics, QAPI, and Behavioral Health were not documented for the affected employees, and the Regional Nurse Consultant confirmed the deficiency.
Failure to Determine Safe Self-Administration of Medications: A resident with HTN, Parkinson’s disease, and dementia had 10 pills left on a bedside table during an observation, with no nurse present. The resident’s chart had no MD order for self-administration and the care plan did not address it, while facility documentation stated the resident did not want to self-administer meds. An LPN said meds should not be left in a resident’s room, and the DON confirmed the facility failed to determine whether self-administration was safe and clinically appropriate.
Failure to Notify Physician of Change in Condition: A resident with dementia, anxiety, and depression had two episodes of behavioral and self-harm-related change in condition, including aggression toward staff, punching himself in the head, suicidal statements, and hitting himself on the head. Although the care plan directed staff to notify the physician of any changes, the record did not show that the MD was notified for either event.
Misappropriation of Resident Funds: The facility failed to ensure that a resident was free from misappropriation of money when two CNA employees received $750 checks from the resident’s RFMS account. Records showed the checks were issued and cashed, and interviews confirmed the resident gave the employees money while staff acknowledged employees should not accept gifts from residents.
Psychotropic medications were ordered for two residents without required documentation. One resident had orders for Sertraline and Seroquel with no diagnosis listed, and another resident had a PRN Ativan order for anxiety/restlessness that lacked a 14-day stop date and physician rationale for use beyond 14 days. The DON acknowledged the missing diagnoses and documentation issues, and an RN stated diagnoses are normally entered with medication orders.
Failure to Complete Pre-Employment Background Check: The facility failed to properly screen an LPN before employment by not completing a state criminal background check prior to the start of work. Facility policy required background checks for all employees, and the HR job description included pre-screening responsibilities such as background checks and maintaining complete employee files. The HR employee confirmed the missing background check during interview.
Failure to Report Neglect and Misappropriation: The facility did not report an incident in which a resident with dementia, Parkinson's Disease, and depression was found with an open cleanser bottle and appeared to have ingested soap, despite staff, Poison Control, and the provider being involved. The facility also did not report misappropriation involving a resident whose RFMS account showed two $750 checks written to two NAs and cashed, with the BOM confirming the resident could not write his own checks and the RNC confirming both events were not reported to the State.
Failure to Communicate Transfer Information and Bed Hold Policy: The facility failed to ensure that necessary transfer information, including the bed hold policy, was communicated to the receiving provider for two residents who were sent to the hospital and expected to return. One resident had HF, arthritis, and a cerebral infarction, and the other had dementia, HF, and diabetes. The DON confirmed there was no documented evidence that the required information was sent.
Failure to timely administer ordered Parkinson's medication. A resident with dementia, Parkinson's disease, and depression had an order for entacapone to be given with the first four daily doses of Sinemet, but the medication was not administered for 12 days after the order was written. The DON and Regional Nurse Consultant confirmed the delay in providing the ordered treatment.
A resident with hemiplegia and CVA had a physician order for a resting hand splint to the LUE at bedtime as tolerated, but the care plan did not include goals or interventions for splint use. Facility policy stated the splint schedule should be communicated to the multidisciplinary team and documented in the care plan, and the DON confirmed the care plan was not developed or implemented for this need.
Failure to Provide Adequate Supervision: A resident with dementia, Parkinson’s Disease, and depression was found in the MIU hall with an open bottle of perineal and skin cleanser and appeared to have ingested some of it. The resident’s care plan called for frequent monitoring and supervised placement when out of bed, but the DON and Regional Nurse Consultant confirmed the facility failed to ensure adequate supervision.
Incomplete dialysis assessment documentation was identified for a resident with CHF, DM, and ESRD who was scheduled for regular HD. The facility policy required pre- and post-dialysis communication and documentation in the dialysis communication tool, but the resident’s chart lacked dialysis communications for the month reviewed, and the Medical Records/Central Supply personnel confirmed the record was incomplete.
The facility failed to complete annual performance evaluations for two nurse aide personnel records. Record review showed both nurse aides had hire dates of 7/1/23, and neither file contained an annual performance evaluation at least every 12 months as required. A Regional Nurse Consultant confirmed the missing evaluations during interview.
A resident with a history of suicidal ideations, dementia, anxiety, and depression had escalating behavioral symptoms, including aggression toward staff, self-hitting, threats to kill himself, and statements asking staff to kill him. The care plan did not include suicidal ideations, the physician was not documented as being notified of several behavior episodes, and psych services were not ordered until later. Interviews with the DON and Social Service Director confirmed the resident did not receive timely psych involvement despite the history and behaviors.
A resident with a hx of suicidal ideation, dementia, anxiety, and depression had a care plan that addressed anxiety-related behaviors but did not include suicidal ideation. Clinical notes documented escalating aggression, threats toward CNAs, self-hitting, and repeated statements that he wanted to die or be killed, yet the record did not show social services involvement for these events and psych was not seen until later.
A resident with dementia, Parkinson’s Disease, and depression was prescribed phenazopyridine for dysuria, but the order had no end date and the medication continued beyond the intended 3-day course. The MRR identified prolonged use and recommended discontinuation, yet the drug remained active until it was later stopped, and the DON and Regional Nurse Consultant confirmed the deficiency.
Incomplete Medication Documentation in Resident Record: A resident’s clinical record contained multiple physician orders for medications without a diagnosis for use, including Tylenol, Docusate Sodium, Famotidine, Lasix, Synthroid, Meropenem, Milk of Magnesia, Montelukast, Omeprazole, Oyster Shell Calcium, Potassium Chloride, Qulipta, and Solifenacin. The DON acknowledged that medications without diagnoses had been seen, and an RN stated diagnoses are supposed to be entered with orders; the DON later confirmed the record was incomplete and inaccurately documented.
QAA committee meetings were not held quarterly with all required members present for two reviewed quarters. Sign-in sheets showed the Medical Director and Infection Preventionist were absent from one quarter’s meetings, and the DON and Infection Preventionist were absent from another quarter’s meetings; a Regional Nurse Consultant confirmed the deficiency.
A facility failed to provide the required 12 hours of annual NA training for one of five NA personnel records reviewed. The NA had a hire date of 7/1/23 and only 4.67 hours of in-service education documented for the year reviewed, and the Regional Nurse Consultant confirmed the deficiency during interview.
Incomplete COVID-19 Vaccine Documentation: The facility failed to accurately and timely document COVID-19 vaccine education, offers, and status for two residents. One resident had moderate cognitive impairment, COPD, depression, and epilepsy, while the other had quadriplegia, CVA, and a vitamin deficiency. Records showed both were not up to date with the COVID-19 vaccine, but the chart lacked documentation that an up-to-date booster was offered and that education was provided to the resident or guardian.
Failure to post current nurse staffing information. The facility posted nurse staffing information near the main entrance that was outdated, listed an incorrect resident census, and did not accurately reflect the current hours worked by licensed and unlicensed nursing staff directly responsible for resident care. A Regional Nurse Consultant confirmed the required staffing hours and census were not posted accurately.
The facility did not consistently follow procedures for counting and documenting controlled medications during shift changes, as required by policy. This led to a medication error where a resident with anxiety and depression received two doses of lorazepam in one morning due to poor communication and incomplete documentation between LPNs. Staff interviews confirmed that agency and night shift staff often failed to complete the required counts.
Two residents experienced significant medication errors when one received duplicate doses of lorazepam in the morning due to miscommunication and poor documentation among LPNs, and another was given an incorrect dose of chlordiazepoxide at bedtime on two occasions. Both incidents were identified through record review and staff interviews, with no adverse effects reported for the residents involved.
A resident with prostate cancer did not receive multiple scheduled doses of a prescribed cancer medication due to unavailability, and the physician was not notified of these missed doses as required by facility policy. The DON confirmed there was no documentation of physician notification, despite ongoing issues with medication supply and the resident's refusal to allow family involvement.
A resident with prostate cancer did not receive prescribed Nubeqa for multiple days because the medication was unavailable and the facility was unable to obtain it from the family or pharmacy. The resident, acting as his own responsible party, refused to authorize communication with family members who could supply the medication and did not provide clear instructions to staff, resulting in missed doses.
A resident with a history of prostate cancer did not receive multiple scheduled doses of a prescribed cancer medication because the drug was unavailable. The medication had previously been supplied by a family member, but when this was no longer possible, the resident refused to authorize the facility to coordinate with another family member or to provide direction for obtaining the medication through the facility pharmacy. This resulted in repeated missed doses, as confirmed by the DON.
Kittanning Health and Rehab Center was found deficient in maintaining documentation for annual emergency preparedness training and testing for staff, as required by 42 CFR 483.73. The deficiency was confirmed through a document review and an interview with the maintenance supervisor, revealing a lapse in compliance with regulatory requirements.
The facility did not maintain documentation for the cleaning and testing of carbon monoxide detectors for eight of the past twelve months, as required by PA Act #45. The facility attributed the lack of documentation to destruction caused by a water leak, a fact confirmed by the maintenance supervisor.
The facility did not maintain proper documentation for emergency lighting tests as required by NFPA 101, affecting the entire facility. Missing records included monthly 30-second and annual 90-minute tests, confirmed by the maintenance supervisor.
The facility failed to maintain exit and directional signage as required by NFPA 101 standards. Blinds covered 'NOT AN EXIT' signs on the MIU unit courtyard doors, and the facility lacked documentation for monthly exit sign inspections over the past year. These issues were confirmed by the maintenance supervisor.
The facility did not maintain the fire alarm system as required by NFPA standards. Observations during a survey revealed the fire alarm panel was in 'Service mode' with a 'TROUBLE' message, and the facility lacked documentation for the two-year smoke detector sensitivity testing. These issues were confirmed by the maintenance supervisor.
The facility was found non-compliant with sprinkler system regulations due to dust-covered, dirty, and corroded sprinkler heads in the kitchen dishwashing area. Additionally, the third quarter inspection documentation was unavailable during the survey. The maintenance supervisor confirmed these deficiencies.
The facility did not meet fire drill requirements, lacking documentation for 11 of 12 required drills. A review showed missing records for various shifts across all quarters, attributed to document destruction from a water leak. This was confirmed by the maintenance supervisor.
The facility did not conduct the required annual testing and inspection of non-hospital grade electrical receptacles in resident sleeping rooms. The deficiency was identified during a document review and confirmed by the maintenance supervisor, who acknowledged the absence of documentation for these tests.
The facility failed to maintain documentation for essential generator tests for 10 out of 12 months, affecting the entire facility. Missing records included weekly inspections and monthly tests. The maintenance supervisor confirmed the unavailability of documents, which were reportedly destroyed due to a water leak.
The facility failed to maintain proper emergency preparedness documentation, lacking records of an annual full-scale exercise and a tabletop exercise. This deficiency was confirmed by the maintenance supervisor, indicating a significant gap in the facility's emergency readiness.
The facility failed to maintain two exit discharges. One exit discharge near the time clock room had a snow-covered egress path, and another near the employee lounge lacked panic or fire exit hardware. These issues were confirmed by the maintenance supervisor.
The facility failed to maintain self-closing doors, with seven out of over ten doors not functioning properly. Issues included doors not latching, being propped open, or dragging on the floor. These deficiencies were confirmed by the maintenance supervisor.
The facility failed to maintain its kitchen suppression system, with staff unsure of the hood fire suppression system's manual activation and lacking documentation of required inspections. These deficiencies were confirmed by the maintenance supervisor.
The facility failed to maintain smoke barriers in over thirty rooms due to issues with ceiling tiles. Observations revealed loose, misaligned, damaged, and missing tiles on the main floor, and water damage in the basement from a ruptured pipe. The missing tiles could delay fire system activation and allow smoke passage. The maintenance supervisor confirmed these deficiencies.
The facility was found to be non-compliant with NFPA standards for electrical power cords. A refrigerator in the administrator's office was plugged into a power strip, and another in the soiled utility room was connected to an extension cord. These issues were confirmed by the maintenance specialist.
A facility failed to meet corridor door requirements when a door to a resident's room did not positively latch, as observed by surveyors. The maintenance supervisor confirmed the deficiency, which is crucial for fire safety and smoke containment.
Medication Administration Errors Resulted in Harm and Missed Insulin Dose
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors for two residents. For Resident R31, the record showed he was admitted with diagnoses including high blood pressure, diabetes, and pain. A nurse practitioner note documented that he became unresponsive after receiving an incorrect opioid medication by error, including oxycontin that was not ordered for him, along with his scheduled Percocet doses. He required 1 mg of Narcan after staff found him lying face down on his bed and difficult to awaken. A written statement from the LPN involved indicated the error occurred when the resident was given the wrong medication from the med card/cart process, and staff interviews confirmed the resident went unresponsive and that the medication count was off. For Resident R53, the record showed diagnoses including high blood pressure, depression, and diabetes, and the care plan directed administration of diabetic medications and insulin as ordered. A physician order required insulin lispro 12 units with breakfast and dinner plus sliding scale. During observation of the medication pass, the LPN failed to prepare or administer the resident’s insulin. The resident confirmed she had already eaten breakfast and had not received insulin, and the LPN acknowledged the insulin was not administered as ordered. The DON later confirmed the facility failed to ensure that residents were free of significant medication errors for this resident.
Insufficient Nursing Staffing and Missed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of 11 of 16 residents, including GR1 through GR9, R51, and R88. Review of PBJ staffing data for two quarterly periods showed the facility had a one-star staffing rating and excessively low weekend staffing. During interviews, residents reported missed or delayed showers because staff were not available, including R88 stating he was supposed to receive two showers per week and required two employees for showers, but did not always get them because the facility did not always have enough employees. R51 stated he was supposed to get showers twice a week but was lucky to get one, and said this was because there were not enough staff. Staff also confirmed the staffing shortage. A resident council group interview found nine of nine residents voicing that the facility was short staffed. An LPN stated the facility did not have enough staff and that the 3 to 11 shift was bad, with residents not getting showers then. A nurse aide stated they had to skip a shower because of no staff, that this happened several times a week and had been worse in the past month, and that all shifts appeared to be short. The nurse aide also reported difficulty getting residents out of bed, finding help for Hoyer lifts, and completing tray pass. The DON confirmed the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for the identified residents.
Emergency Equipment Not Maintained in Safe Operating Condition
Penalty
Summary
The facility failed to make certain that emergency equipment was in safe operating condition for two crash carts, located in the Common Room and the Memory Impaired Unit, and for two Automated External Defibrillators located in the Common Room and Main Dining Room. Review of the facility’s Emergency Equipment Check policy showed that emergency equipment was to be checked daily, with outdated or opened items replaced and the cart restocked promptly after use. However, the Emergency Cart Daily Checklist for the Common Room crash cart had missing signatures for two dates, and the checklist also required daily checks of AED battery life and the presence of pads. During observation of the Common Room crash cart, three suctioning tubing items were found expired and one Ambu bag was opened with a package date of 07/2015. A Registered Nurse confirmed the missing signatures, expired supplies, and missing AED battery checks. During observation of the Memory Impaired Unit crash cart, one Continu-Flo Solution IV tubing, two IV start kits, and three suction tubing items were found expired, and an LPN confirmed these expired supplies. The DON later confirmed that the facility failed to make certain that equipment was in safe operating condition for the two crash carts and the two AEDs.
Failure to Fit Test N-95s During COVID Outbreak and Monitor Resident Refrigerator Temperatures
Penalty
Summary
The facility failed to ensure that staff were fit tested for NIOSH-approved N-95 respirators during a COVID-19 outbreak. A notice of COVID outbreak was posted at the entrance, and the Regional Nurse Consultant/Infection Preventionist confirmed that the facility had positive COVID cases and was in an outbreak. Documentation showed that 11 of 29 residents were in isolation precautions for positive COVID test results or exposure, and isolation signs and PPE were observed on the doors of exposed or confirmed COVID residents. Staff were observed wearing N-95 masks while providing care to these residents during the outbreak period. The Regional Nurse Consultant/Infection Preventionist stated that the facility had not fit tested any staff for N-95 respirators since March 2025 and that no one at the facility was trained to fit test staff. Staff interviews confirmed this, as an RN, an LPN, and a nurse aide each stated they had not been fit tested at the facility despite caring for residents who were COVID positive. The Regional Nurse Consultant/Infection Preventionist later confirmed that the facility failed to ensure fit testing of NIOSH-approved N-95 masks was completed for staff caring for residents with suspected or confirmed COVID during the outbreak. The facility also failed to properly monitor the refrigerator temperatures for Resident R88, who was admitted to the facility and whose MDS listed diagnoses of high blood pressure, thyroid disorder, and chronic pain. A refrigerator temperature log posted above the resident’s personal refrigerator showed missing temperature entries for multiple days in September 2025, no data for all of October 2025, and no logs kept for November or December 2025. The DON confirmed that no refrigerator temperature logs were kept for those later months, and the facility failed to monitor refrigerator temperatures as required.
Failure to Provide Quarterly Resident Trust Fund Statements
Penalty
Summary
The facility failed to provide quarterly resident trust fund statements for four sampled residents with active resident fund accounts: R11, R31, R80, and R88. The facility Resident fund management policy dated 6/10/25 stated that quarterly statements are to be sent by corporate office and that addresses are to be maintained in the resident fund management system. During a resident council group interview on 1/6/26 at 1:00 p.m., three of nine residents stated that the facility had not provided quarterly statements. Review of the facility trust fund account records dated 1/6/25 identified R11, R31, R80, and R88 as having active resident fund accounts, but the facility business records and resident records did not include evidence that quarterly statements were provided. On 1/7/26 at 12:55 p.m., the Business Office Manager confirmed that the facility could not provide evidence of sending quarterly statements and had failed to provide quarterly resident fund statements for these residents as required.
Failure to Close Resident Trust Accounts After Discharge
Penalty
Summary
The facility failed to convey resident funds and close trust accounts within 30 days after discharge for three closed resident records, CR110, CR111, and CR112. The facility’s resident fund management policy stated that trust accounts for discharged or expired residents are to be closed and funds disbursed timely. Review of the trust fund account statement showed that CR110 had a balance of $108.60, CR111 had a balance of $79.50, and CR112 had a balance of $20.03 remaining in open accounts after their records were closed. CR110’s record showed diagnoses including dementia, depression, anxiety disorder, and restlessness, and documentation indicated he ceased to breathe and hospice was notified that he expired. CR111’s record showed diagnoses including dementia, hypertension, and Takotsubo syndrome, and nursing notes documented that staff found her with no audible pulse and a physician note directed release of her body to the morgue or funeral home. CR112’s record showed diagnoses including lumbar fracture, hypertension, and chronic pain, and nursing notes documented that she was found bleeding from the back of her head after an incident in her room, was sent to the hospital, and later had an order indicating she may discharge to another nursing facility. During interview, the Business Office Manager confirmed the facility failed to convey resident funds and close the resident accounts within 30 days upon discharge for CR110, CR111, and CR112.
Inadequate Respiratory Care for Residents Receiving Oxygen and Nebulizer Therapy
Penalty
Summary
Appropriate respiratory care was not provided for three residents who were receiving oxygen therapy and, in one case, nebulizer treatment. Resident R13 had diagnoses of COPD, asthma, and dementia, and had a physician order for oxygen via nasal cannula at 2 liters per minute as needed for shortness of breath. During observation, R13 was lying in bed with oxygen in use, the concentrator was beside the bed, and the oxygen tubing was dated 12/15/25. Resident R36 had diagnoses of high blood pressure, diabetes, and asthma, with an order for oxygen via nasal cannula at 2 liters per minute at bedtime as needed for comfort. During observation, R36 was lying in bed with oxygen in use, the concentrator was beside the bed, and the oxygen tubing had no date showing when it was changed; the humidification was connected to the concentrator and also had no date showing when it was put into use. Resident R100 had diagnoses of COPD, asthma, and heart failure, with an order for oxygen via nasal cannula at 3 liters per minute continuously and humidification for comfort if needed, plus an order for ipratropium-albuterol via nebulizer every 4 hours as needed. During observation, R100 was lying in bed with oxygen in use, the oxygen tubing was dated 12/15/25, the humidification bottle was empty and undated, and the nebulizer tubing was dated 11/11/25 and was not stored in a bag when not in use. An LPN stated that oxygen and nebulizer tubing should be changed weekly and stored in a bag when not in use, and the DON confirmed the facility failed to provide appropriate respiratory care for these three residents.
Missing Physician Responses for Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure physician response for medication regimen reviews (MRR) for four of six sampled residents: R2, R5, R9, and R71. The facility Medication Regimen Review policy, last reviewed 6/18/25, stated that each resident’s drug regimen review is completed at least monthly by the consultant pharmacist and that any irregularities are reported, with physician/prescriber or other responsible parties and the DON encouraged to act on recommendations. Review of the clinical record showed that Resident R2, who had diagnoses of high blood pressure, bipolar disorder, and wound infection, had MRR documentation on 1/8/26 indicating the facility failed to provide completed MRRs by the attending physician for November and December 2025. Resident R5, with diagnoses of dementia, heart failure, and diabetes, had MRR documentation showing missing physician completion for June through October 2025. Resident R9, diagnosed with heart failure, diabetes, and anxiety, had MRR documentation showing missing physician completion for February and March 2025 and again for September through December 2025. Resident R71, diagnosed with dementia, Parkinson's Disease, and depression, had an MRR dated 12/18/25 that identified Phenazopyridine had been given for symptomatic relief of dysuria greater than two days, noted that prolonged use may mask symptoms of unresolved cystitis and increase the risk of complications, and recommended discontinuation of Phenazopyridine; however, the MRR failed to include a physician response. During interviews on 1/7/26 and 1/8/26, the DON and Regional Nurse Consultant confirmed the facility failed to provide documentation of physician-signed MRRs for Resident R71 and failed to ensure MRRs were completed for four of six residents.
Missing Required Annual Staff Training
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for all new and existing staff members. Review of personnel files and in-service documentation showed that three of five files reviewed were missing required annual training for 2025. An LPN hired on 10/2/23 did not have annual in-service training documented for Effective Communication, Resident Rights, Abuse, QAPI, Infection Control, Compliance and Ethics, and Behavioral Health. A nurse aide hired on 7/1/23 did not have annual in-service training documented for Effective Communication, Resident Rights, Abuse, Infection Control, Compliance and Ethics, and Behavioral Health. Another LPN hired on 7/1/23 did not have annual in-service training documented for QAPI and Behavioral Health. During interview, the Regional Nurse Consultant confirmed that the facility failed to implement and maintain an effective training program for these three employees.
Failure to Determine Safe Self-Administration of Medications
Penalty
Summary
The facility failed to determine whether it was safe and clinically appropriate for Resident R77 to self-administer medications. The resident’s record showed diagnoses of high blood pressure, Parkinson’s disease, and dementia. The facility policy on Self-Administration of Medications dated 6/18/25 stated that the facility should assess whether self-administration is safe based on the resident’s functionality and health condition, and that orders for self-administration should list the specific medications the resident may self-administer. During an observation on 1/5/26 at 10:17 a.m., Resident R77 was sitting on the edge of the bed with a bedside table that had a paper towel holding 10 medication pills, including four white pills, two yellow pills, two red pills, one peach pill, and one pink pill, with no nurse present in the room. The resident’s physician orders did not include an order for self-administration of medications, and the care plan did not address self-administration. Facility documentation labeled Self-Administration of Medications dated 11/30/25 indicated that the resident did not want to self-administer medications. An LPN stated that medications should not be left in a resident’s room and that staff are supposed to watch residents take them, and another LPN stated that she would not leave medications in a room for residents to take. The DON confirmed the facility failed to determine whether it was safe to self-administer medications for Resident R77.
Failure to Notify Physician of Resident Change in Condition
Penalty
Summary
The facility failed to ensure the physician was appropriately notified of changes in condition for Resident R99. The resident was admitted with diagnoses of dementia, anxiety, and depression, and the care plan directed staff to notify the physician of any changes. On 9/4/25, the resident began swinging at staff and then punched himself on the head during evening care; he was redirected and placed at the nursing station for monitoring, but the clinical record did not show that the physician was notified of this change in condition. On 10/13/25, the resident again had a change in condition when he repeatedly stated he wanted to die, asked staff to kill him, and hit himself on the head. The clinical record also did not reveal evidence that the physician was notified of this event. The facility policy stated that the physician and family would be notified as soon as the nurse identified the change in condition and the resident was stable, but the record did not show physician notification for either incident.
Misappropriation of Resident Funds
Penalty
Summary
The facility failed to ensure that residents were free from misappropriation of property for one resident, R88. The facility policy stated that abuse, neglect, mistreatment, exploitation, and misappropriation of resident property would not be tolerated, and defined exploitation as the unfair treatment or use of a resident or taking advantage of a resident for personal gain. R88’s clinical record showed admission to the facility and an MDS dated 11/12/25 listed diagnoses of high blood pressure, thyroid disorder, and chronic pain. Facility records and interviews showed that two checks for $750 each were issued from R88’s RFMS account to two nurse aides, E29 and E30, on 4/22/25, and both checks were cashed and cleared on 4/25/25. The BOM stated that R88 could not write his own checks and that the former BOM would have had to write the checks from the account. The BOM also stated that R88 had asked for a check to his credit union and that she later found the checks to the employees. R88 stated that he gave two employees $750 and that they got fired. The RNC confirmed that employees should not accept gifts from residents, but stated it was not felt to be misappropriation because R88 was alert and oriented; the State Agency reminded the RNC that the regulation includes monetary assistance to staff as an example of misappropriation.
Psychotropic Medications Lacked Required Diagnoses and PRN Limits
Penalty
Summary
The facility failed to ensure that two residents’ medication regimens were free from unnecessary psychotropic medications. For one resident, the clinical record showed physician orders for Sertraline 100 mg daily and Seroquel 200 mg daily, but the orders did not include a diagnosis for use. The resident’s MDS listed diagnoses of high blood pressure, bipolar disorder, and wound infection. During interview, the DON stated that medications did not have diagnoses and that she had been working on it, while an RN stated that diagnoses are entered when orders are put in and that it had been emphasized over the years to do so. For another resident, the clinical record showed a physician order dated 10/16/25 for Ativan 1 mg every two hours as needed for anxiety/restlessness. The order did not include a 14-day stop date, and there was no documented physician rationale for extending the PRN medication beyond 14 days, as required by facility policy. The resident’s MDS listed diagnoses of heart failure, diabetes, and anxiety. During interview, the DON confirmed that the resident’s medications did not include a diagnosis for use and that the facility failed to make certain the medical record was complete and accurately documented for one resident, and failed to ensure that the resident’s medication regimen was free from unnecessary psychotropic medication for another resident.
Failure to Complete Pre-Employment Background Check
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft was cited after the facility failed to properly screen an employee before employment. Review of the facility policy showed that background checks are required for all employees and applicable records must be retained. Review of the Payroll/Human Resources Coordinator job description showed that pre-screening responsibilities include license verification, exclusion checks, background checks, and maintaining complete employee files. Review of LPN Employee E9’s personnel file showed a hire date of 9/25/25, but the file did not contain a completed state criminal background check prior to the date of hire. During an interview on 1/7/26 at 10:31 a.m., the Human Resources employee confirmed that the facility failed to conduct a criminal background check prior to the start of employment for this employee.
Failure to Report Neglect and Misappropriation
Penalty
Summary
The facility failed to report an incident of neglect involving Resident R71 to the State Agency. Resident R71 had diagnoses of dementia, Parkinson's Disease, and depression, and care plans directed staff to monitor the resident frequently and observe her in a supervised area when out of bed. On 12/4/25, the resident was found in the MIU hall sitting in a chair with a bottle of perineal and skin cleanser open and appeared to have drank some of the soap. Poison Control was contacted and said the product was non-toxic and to monitor the resident, and the on-call provider gave the same direction. The resident's family was notified. A nurse aide witness stated the resident was seen running up the hallway with the bottle and then tipping it back in her mouth. Review of information submitted to the State on 12/4/25 and 12/5/25 did not include this incident of neglect, and the Regional Nurse Consultant confirmed the failure to report it. The facility also failed to report misappropriation of money involving Resident R88. Resident R88 had diagnoses of high blood pressure, thyroid disorder, and chronic pain. The Business Office Manager reviewed the resident's RFMS account and found two checks for $750 each written to two nurse aides, both cashed and cleared. The BOM stated the resident was not able to write his own checks and that the former BOM would have had to write them from the account. The resident stated he gave two employees $750 and said they were fired. Review of information submitted to the State Agency from 11/24/25 through 1/8/26 did not include the misappropriation of money, and the Regional Nurse Consultant confirmed the failure to report it.
Failure to Communicate Transfer Information and Bed Hold Policy
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider for two residents who were transferred to the hospital and expected to return, including the bed hold policy. Review of the facility’s discharge planning policy indicated that transfers and discharges are to be documented in the resident’s medical record and that necessary information is to be communicated to the receiving health care institution or provider. The facility’s bed hold policy also indicated that bed hold days are to be tracked and appropriate parties notified via bed hold letter. Resident R1 had diagnoses including heart failure, arthritis, and cerebral infarction, and was transferred to the hospital and later returned to the facility. Resident R5 had diagnoses including dementia, heart failure, and diabetes, and was also transferred to the hospital and later returned. Review of both residents’ clinical records found no documented evidence that the facility communicated specific information to the receiving health care provider, including the bed hold policy, for these facility-initiated transfers. During interview, the DON confirmed that the facility failed to make certain that the necessary resident information was communicated for these two of four sampled residents with facility-initiated transfers.
Failure to Timely Administer Ordered Parkinson's Medication
Penalty
Summary
The facility failed to provide care and treatment as ordered by the physician for Resident R71, who was admitted with diagnoses of dementia, Parkinson's disease, and depression. The resident's care plan dated 4/22/25 indicated Parkinson's disease and directed drug therapy per order, and the MDS dated 10/8/25 showed the diagnoses were current. A neurology after-visit summary dated 11/19/25 ordered entacapone 20 mg, one tablet four times a day with each of the first four doses of Sinemet to extend the benefit of Sinemet and shorten wearing off. A progress note dated 11/22/25 documented the resident was seen by CRNP E21 after the neurology follow-up and that entacapone 200 mg was recommended with the first four doses of Sinemet. The physician order dated 12/1/25 directed entacapone 200 mg, one tablet, four times a day with the first four daily doses of Sinemet, and the facility failed to timely administer the medication for 12 days after it was ordered. During interview on 1/7/26, the DON and Regional Nurse Consultant, E1, confirmed the facility failed to timely administer the entacapone as ordered.
Failure to Include Resting Hand Splint in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive resident-specific plan of care for a resident with limited mobility who required equipment and assistance to maintain or improve mobility. Resident R10 was admitted to the facility and had an MDS dated 11/12/25 that identified hemiplegia and CVA. A physician’s order dated 9/5/25 directed the resident to wear a resting hand splint to the left upper extremity nightly as tolerated at bedtime. Review of the care plan showed that it did not include goals or interventions related to the resident’s resting hand splint use, despite the facility policy stating that the splint schedule would be communicated to the multidisciplinary team and documented in the care plan. During interview, the DON confirmed that the facility failed to develop and implement a comprehensive resident-specific care plan for the resident’s resting hand splint.
Failure to Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision for a resident with dementia, Parkinson’s Disease, and depression, despite care plan directions to monitor the resident frequently within the unit and to observe frequently and place the resident in a supervised area when out of bed. The resident was admitted to the facility and had an MDS dated 10/8/25 documenting those diagnoses. The facility policy defined an incident as any occurrence not consistent with routine care, and the record shows an incident involving the resident in the MIU. A progress note dated 12/4/25 at 8:34 p.m. stated the resident was found sitting in a chair in the MIU hall with an open bottle of [NAME] Perineal and Skin Cleanser and appeared to have drank some of the soap. Poison Control was called and verified the product was non-toxic, and the on-call provider was notified. During interview, the DON and Regional Nurse Consultant confirmed the facility failed to make certain the resident received adequate supervision to prevent the ingestion of the skin cleanser.
Incomplete Dialysis Assessment Documentation
Penalty
Summary
The facility failed to maintain a complete record of pre- and post-dialysis assessments for one resident who required hemodialysis services. The facility’s hemodialysis care policy, last reviewed 6/18/25, stated that communications between the dialysis provider and facility staff would occur before and after each dialysis appointment and that the assessment would be documented in the dialysis communication tool. Resident R11 was admitted and later re-admitted to the facility, and her MDS dated 11/5/25 listed congestive heart failure, diabetes, and end stage renal disease. Her care plan directed staff to follow up with the dialysis book, chart, and record information as noted, and a 5/10/25 entry indicated she was to be sent to dialysis on Monday, Wednesday, and Friday. Clinical nurse notes showed she went out to dialysis on 9/26/25 at 9:00 a.m., but review of her clinical nurse notes, physician notes, and dialysis communication documentation did not include dialysis communications for September 2025. During interview on 1/9/26, Medical Records/Central Supply personnel E16 confirmed the facility failed to maintain a complete record of pre- and post-dialysis assessments for Resident R11 as required.
Missing Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance evaluations at least once every 12 months for two of five nurse aide personnel records, identified as NA Employees E11 and E19. Review of NA Employee E11's personnel record showed a hire date of 7/1/23 and did not include an annual performance evaluation at least every 12 months as required. Review of NA Employee E19's personnel record also showed a hire date of 7/1/23 and likewise did not include an annual performance evaluation at least every 12 months as required. During an interview, the Regional Nurse Consultant confirmed that the facility failed to complete annual performance evaluations at least once every 12 months for these two nurse aide personnel records.
Failure to Address Resident’s Suicidal Ideations and Escalating Behaviors
Penalty
Summary
The facility failed to ensure a resident with a history of suicidal ideations, dementia, anxiety, and depression received appropriate behavioral health services to maintain the highest practicable well-being. The resident’s care plan addressed anxiety and included interventions such as monitoring for adverse medication effects, assessing whether anxiety endangered the resident or others, and obtaining a psych consult/psychosocial therapy, but it did not include suicidal ideations. The facility’s psychotropic medication policy stated the resident or representative should be involved in discussions of non-pharmacologic and medication interventions, with documentation in the medical record. The resident’s record documented escalating behavioral concerns, including swinging at staff and punching himself in the head during evening care, increasing aggression during late evening and night shifts, yelling and screaming, inability to be redirected, punching and spitting at staff, threatening physical violence, threatening to shoot and choke CNAs, disturbing other residents, and punching and slapping himself. A later progress note documented the resident stating he wanted to die and asking staff to kill him while hitting himself on the head. The record failed to show the physician was notified of the behaviors documented on 9/4/25, 9/27/25, and 10/13/25, and physician orders did not include psych services. The resident did not receive a behavioral health comprehensive diagnostic evaluation until 10/14/25, where the resident denied active suicidal ideations, intent, or plan, and the evaluation noted a history of depression, suicidal ideations, and dementia-related behavioral disturbances. During interviews, the DON and Social Service Director stated residents with suicidal ideation typically receive an immediate psych consult and suicide screening, and the Social Service Director confirmed the resident did not see psych services until 10/14/25 and that the facility failed to address the resident’s suicide ideations and behaviors timely.
Failure to Provide Timely Social Services for Resident With Suicidal Ideation and Escalating Behaviors
Penalty
Summary
The facility failed to provide sufficient and timely social services for Resident R99, who had a history of suicidal ideations, dementia, anxiety, and depression. The resident’s care plan dated 8/21/25 addressed behavioral symptoms related to anxiety and included interventions to monitor medication side effects, assess whether anxiety endangered the resident or others, intervene as necessary, and obtain a psych consult/psychosocial therapy, but it did not include suicidal ideations. The MDS dated 8/22/25 indicated the diagnoses were current. Clinical documentation showed escalating behavioral concerns that were not addressed by social services in the record. On 9/4/25, the resident swung at staff and began punching himself in the head. On 9/27/25, the resident was documented as increasingly aggressive, yelling, screaming, punching and spitting at staff, threatening physical violence, threatening to shoot and choke CNAs, disturbing other residents, and punching and slapping himself while agitated; the note stated this information had been passed on in daily report, but no new orders or treatments were noted. On 10/13/25, the resident was documented multiple times stating he wanted to die, asking staff to kill him, and hitting himself on the head. The record failed to show evidence that social services addressed these behaviors or the suicidal ideations, and the Social Service Director confirmed the resident did not see psych until 10/14/25.
Unnecessary Medication Use Not Addressed for One Resident
Penalty
Summary
The facility failed to ensure that one resident’s drug regimen was free from unnecessary drugs. Resident R71, who had diagnoses of dementia, Parkinson’s Disease, and depression, was evaluated for dysuria and was prescribed phenazopyridine 200 mg three times a day for three days. The physician order entered on 12/13/25 did not include an end date for the medication. The medication regimen review completed on 12/18/25 identified that the resident had received phenazopyridine for symptomatic relief of dysuria for more than two days and noted that prolonged use may mask the symptoms of unresolved cystitis and increase the risk of complications. The review recommended discontinuing phenazopyridine, and the medication was not discontinued until 12/26/25, which was 11 days after it was to be discontinued. During an interview on 1/7/26, the DON and Regional Nurse Consultant confirmed the facility failed to ensure the resident’s drug regimen was free from unnecessary drugs.
Incomplete Medication Documentation in Resident Record
Penalty
Summary
Medical records were not complete and accurately documented for one resident when physician orders for multiple medications did not include a diagnosis for use. The resident’s record showed an admission to the facility and an MDS dated 11/14/25 listing diagnoses of high blood pressure, bipolar disorder, and wound infection. Review of the clinical record found orders for Tylenol 325 mg every six hours, Docusate Sodium 100 mg at bedtime, Famotidine 20 mg daily, Lasix 20 mg every other day, Synthroid 50 mcg daily, Meropenem 500 mg every eight hours, Milk of Magnesia 400 mg daily as needed, Montelukast 10 mg at bedtime, Omeprazole 20 mg daily, Oyster Shell Calcium one tablet at bedtime, Potassium Chloride 20 mEq twice daily, Qulipta 60 mg daily, and Solifenacin 5 mg daily, all without a diagnosis indicated for use. During interview, the DON stated that medications without diagnoses had been seen and that she had been working on it. An RN stated that when orders are entered, the diagnosis for the medication is supposed to be included. The DON later confirmed that the resident’s medications did not include a diagnosis for use and that the facility failed to make certain the medical record was complete and accurately documented for this resident.
QAA Committee Failed to Meet Quarterly With Required Members
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all required committee members for two of four quarters reviewed, specifically January 2025 through March 2025 and July 2025 through September 2025. Review of QAA Committee meeting sign-in sheets for January through March 2025 did not show attendance by the Medical Director or Infection Preventionist, and review of sign-in sheets for July through September 2025 did not show attendance by the DON or Infection Preventionist. During interview, the Regional Nurse Consultant confirmed that the facility failed to conduct QAA meetings at least quarterly with all required committee members as required.
Failure to Provide Required Annual Nurse Aide Training
Penalty
Summary
The facility failed to conduct the minimum 12 hours of nurse aide training per year for one of five nurse aide personnel records reviewed, identified as NA Employee E11. Review of the personnel record showed a hire date of 7/1/23 and only 4.67 hours of in-service education documented from 1/1/25 through 12/31/25. During an interview on 1/7/26 at 11:31 a.m., the Regional Nurse Consultant, Employee E1, confirmed that the facility did not provide the required minimum annual nurse aide training for NA Employee E11.
Incomplete COVID-19 Vaccine Documentation
Penalty
Summary
The facility failed to provide accurate and timely documentation related to the COVID-19 vaccine for two residents, identified in the report as R83 and R95. Facility policy stated that prior vaccinations are to be asked about at admission, documented in the immunization portal, and tracked by the Infection Preventionist to ensure vaccines are administered timely. Review of the clinical record for R83 showed the resident was admitted to the facility, had diagnoses of depression, COPD, and epilepsy, and had an MDS BIMS score of 11, indicating moderate cognitive impairment. The MDS also coded the resident as not up to date with the COVID-19 vaccine, and the last documented COVID-19 vaccination was on 11/27/23. For R83, the clinical documentation on 10/17/25 stated that no consent for vaccine was obtained and the resident refused, but the record failed to include documentation on 1/7/26 that an up-to-date COVID-19 booster was offered and that education was provided to the resident's guardian. Review of R95's clinical record showed the resident was admitted to the facility, had diagnoses of quadriplegia, cerebral infarction, and vitamin deficiency, and the MDS coded the resident as not up to date with the COVID-19 vaccine. The last documented offer of a COVID-19 vaccination for R95 was 11/14/23, and the record failed to include documentation on 1/7/26 that an up-to-date COVID-19 booster was offered and that education was provided to the resident that year. During interview, the Regional Nurse Consultant confirmed the facility had no documentation that R83 and R95 were offered a COVID-19 vaccination this year and confirmed the documentation failure for both residents.
Failure to Post Current Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that current and accurate nurse staffing information was posted at the beginning of each shift. During an observation on 1/8/26 at 1:12 p.m., the nurse staffing information posted near the main entrance was dated 1/3/26 and contained an incorrect resident census. The staffing hours also did not accurately reflect the current total number of hours worked for licensed and unlicensed nursing staff directly responsible for nursing care per shift. During an interview on 1/8/26 at 1:22 p.m., the Regional Nurse Consultant confirmed that the facility failed to post the required current staffing hours and census for 1/8/26.
Failure to Accurately Account for and Administer Controlled Medications
Penalty
Summary
The facility failed to implement and follow procedures for the accurate accounting of controlled medications on two medication carts, as required by facility policy. Review of controlled substance count logs revealed that on multiple occasions, both oncoming and outgoing nurses did not sign the verification sheets during shift changes to confirm the counts of controlled drugs. This lapse was confirmed by staff interviews, with LPNs noting that agency and night shift staff often neglected to complete the required counts and documentation. Additionally, the facility failed to ensure the accurate administration of medications, resulting in a medication error for one resident. The resident, who had diagnoses of anxiety, depression, and a history of falls, was prescribed lorazepam 0.5 mg three times daily. On one occasion, the resident received two doses of lorazepam in the morning—once at 7:00 a.m. and again at 10:00 a.m.—due to a lack of communication and documentation between shifts. The error was discovered when staff realized the medication had been signed out and administered twice, with no clear record of the first administration or proper handoff between nurses. Staff interviews and witness statements indicated confusion and lack of clarity during shift changes, with one LPN admitting uncertainty about whether the medication was actually given. The incident was documented in the resident's clinical record, and the nursing home administrator confirmed the facility's failure to follow procedures for controlled medication accounting and administration, resulting in the identified medication error.
Failure to Prevent Significant Medication Errors for Two Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by incidents involving two residents. For one resident with diagnoses of anxiety, depression, and a history of falls, a physician order required lorazepam 0.5 mg to be administered three times daily. On one occasion, the resident received lorazepam twice in the morning—once at 7:00 a.m. and again at 10:00 a.m.—due to miscommunication and lack of proper documentation between LPNs on different shifts. The narcotic log and witness statements revealed confusion regarding whether the medication had been administered, with one nurse unsure if she had given the dose and another not noticing the duplication until the end of her shift. There was also a lack of documentation in the electronic medical record and no report from the midnight shift nurse regarding unscheduled or PRN medication administration. Another resident with depression, anxiety, and chronic pain had physician orders for chlordiazepoxide 10 mg in the morning and 5 mg at bedtime. On two consecutive days, the resident was given 10 mg at bedtime instead of the prescribed 5 mg. This error was identified after a review of the medication administration records, and both the CRNP and the resident's representative were notified. In both cases, the residents did not exhibit adverse effects from the medication errors. The Nursing Home Administrator confirmed that the facility did not ensure residents were free from significant medication errors for these two residents.
Failure to Notify Physician of Missed Cancer Medication Doses
Penalty
Summary
The facility failed to ensure that a physician was appropriately notified of multiple missed medication doses for a resident with a history of prostate cancer, high blood pressure, and depression. The resident had a physician order for Nubeqa, a medication used to decrease the growth and spread of prostate cancer, to be administered twice daily. Review of the Medication Administration Record showed that the medication was not administered over several consecutive days due to it being unavailable, with documentation indicating reasons such as the medication being reordered but not yet arrived, family to provide, or simply unavailable. On one occasion, the medication was not administered due to resident refusal. Despite the ongoing unavailability of the medication, there was no documentation that the physician was notified of the missed doses, as confirmed by the Director of Nursing. Facility policy required immediate action to obtain unavailable medications and to notify the physician and resident/family when there was a need to alter medical treatment, including changes in provider orders. The resident was his own responsible party and had declined to allow the facility to communicate with his brother regarding the medication, further complicating the situation. However, the lack of physician notification regarding the missed doses constituted a failure to follow facility policy and regulatory requirements.
Failure to Provide Physician-Ordered Medication Due to Supply and Communication Issues
Penalty
Summary
The facility failed to provide a prescribed cancer medication, Nubeqa, as ordered by the physician for a resident with a history of prostate cancer, high blood pressure, and depression. According to the Medication Administration Record, the medication was not administered on multiple occasions over several days due to it being unavailable. Documentation indicated that the medication was to be supplied by the resident's family, but there were repeated notations that it had not arrived or was unavailable. The facility's policy requires staff to take immediate action to obtain medications from the pharmacy or seek alternate physician orders if the medication cannot be obtained, but this was not documented as having occurred. Interviews with the DON revealed that the resident's brother had previously supplied the medication out-of-pocket, but was no longer able to do so. Another family member was willing to assist, but the resident, who is his own responsible party, refused to allow the facility to communicate with his brother regarding his care. The resident also did not provide clear direction to the facility on how to proceed with obtaining the medication, and at times refused to discuss the matter. As a result, the facility did not provide the medication as ordered for an extended period.
Failure to Prevent Significant Medication Error Due to Unavailable Cancer Medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of Nubeqa, a medication prescribed to decrease the growth and spread of prostate cancer. The resident, who had diagnoses including high blood pressure, depression, and a history of prostate cancer, had a physician's order for Nubeqa 600 mg by mouth twice daily. Review of the Medication Administration Record for April showed that the medication was not administered on multiple occasions due to it being unavailable, with documentation indicating issues such as the medication not arriving, the family being responsible for supply, and ongoing unavailability. Interviews with the Director of Nursing revealed that the resident's brother had previously provided the medication out-of-pocket, but was no longer able to do so. Although another family member was willing to assist, the resident, who is his own responsible party, refused to allow the facility to communicate with his brother or provide direction on how to obtain the medication through the facility's pharmacy. As a result, the resident missed numerous doses of the prescribed cancer medication over several days, constituting a significant medication error as required by facility policy and state regulations.
Deficiency in Emergency Preparedness Training Documentation
Penalty
Summary
Kittanning Health and Rehab Center was found to have a deficiency related to emergency preparedness training and testing as per the requirements of 42 CFR 483.73. During an emergency preparedness survey conducted on January 22, 2025, it was discovered that the facility failed to provide documentation proving that all staff had received the required annual emergency preparedness training and testing within the previous twelve months. This lack of documentation was confirmed during an interview with the maintenance supervisor. The deficiency was identified through a document review and an interview conducted on the same day. The absence of documentation indicates that the facility did not adhere to the regulatory requirement to maintain an updated emergency preparedness training and testing program. This oversight suggests a lapse in ensuring that staff are adequately prepared for emergency situations, although the report does not specify any immediate consequences or risks resulting from this deficiency.
Plan Of Correction
The Emergency Preparedness Plan (EPP) was reviewed and updated as necessary. The Emergency Preparedness Plan is to be reviewed and updated at least annually based on the most recent documented, facility-based and community-based risk assessment using an all-hazards approach. NHA/designee to complete annual full-scale exercise/table-top exercise by 21MAR2025. NHA/designee to educate all staff by 21MAR2025 on the Emergency Preparedness Plan and annual testing requirements to ensure a comprehensive understanding of policies and procedures and staff readiness. RVPO/designee to educate NHA by 21MAR2025 on the requirements of Emergency Preparedness Plan Guidelines and staff annual EPP training requirements. To prevent this from recurring, RVPO will complete annual audits on facility EPP to ensure current updated version. Negative findings will be addressed. Ad Hoc education will be provided. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendation.
Failure to Maintain Carbon Monoxide Detector Records
Penalty
Summary
The facility failed to comply with the requirements for testing and cleaning carbon monoxide detectors as mandated by PA Act #45. During a document review on January 22, 2025, it was discovered that the facility did not have documentation to confirm that the carbon monoxide detectors had been cleaned or tested for eight of the previous twelve months. The facility claimed that the documents were destroyed due to a water leak. This deficiency was confirmed during an interview with the maintenance supervisor on the same day.
Plan Of Correction
Maintenance immediately cleaned and tested carbon monoxide detectors throughout the building and documented the results. Maintenance completed an audit of carbon monoxide detectors throughout the facility to ensure function and documented with no negative findings. NHA/Designee to educate Maintenance department by 21MAR2025 on the importance of maintaining proper service records for cleaning/testing of carbon monoxide detectors. To prevent this from recurring, Maintenance will perform weekly x4 audits on carbon monoxide detectors for cleanliness and function. Negative findings will be addressed. Ad Hoc education will be provided. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Failure to Maintain Emergency Lighting Documentation
Penalty
Summary
The facility failed to maintain emergency lighting in compliance with NFPA 101 regulations, affecting the entire facility. During a document review, it was found that the facility could not provide documentation for the required emergency lighting tests over the previous 12 months. Specifically, the facility lacked records for monthly 30-second testing and annual 90-minute testing. This deficiency was confirmed through an interview with the maintenance supervisor.
Plan Of Correction
A. Monthly 30-second testing Maintenance performed emergency 30-second lighting test and documented testing results. Maintenance will maintain monthly audit of 30-second lighting testing and documentation. NHA/Designee to educate Maintenance staff by 21MAR2025 on emergency lighting 30-second testing and maintaining documentation. Maintenance Director/Designee to complete monthly x3 audit of emergency lighting test documentation. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. B. Annual 90-min testing Maintenance will complete 90 minute annual testing by 3/21/25 and document. Maintenance will complete annual testing thereafter. NHA/Designee will educate maintenance staff by 21MAR2025 on emergency lighting 90-min testing and documenting annually to remain in compliance. NHA/Designee to complete routine audits of maintenance documentation records. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Deficiency in Exit Signage Maintenance
Penalty
Summary
The facility failed to maintain proper exit and directional signage throughout the building, as required by NFPA 101 standards. During a survey conducted on January 22, 2025, it was observed that the MIU unit courtyard doors had blinds covering the 'NOT AN EXIT' signs, obstructing visibility. Additionally, the facility was unable to provide documentation for monthly exit sign inspections for the previous 12 months. These deficiencies were confirmed during an interview with the maintenance supervisor on the same day.
Plan Of Correction
A. MIU Courtyard Door: Maintenance immediately removed all blinds that were covering courtyard "NOT AN EXIT" sign. Maintenance completed exit sign inspection and documented findings. No additional negative findings. NHA/Designee to educate maintenance staff by 21MAR2025 on exit signage visibility. Maintenance/designee will complete weekly x 4 audits of exit signage to ensure proper display. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. B. Facility couldn't provide documentation for monthly 12 month exit sign inspection: Maintenance performed immediate exit sign inspection and documented findings. Maintenance will keep proper documentation for monthly exit sign inspection. NHA/Designee will educate Maintenance staff by 21MAR2025 on exit sign inspection and documentation. NHA/Designee will complete exit sign inspection documentation audits monthly x 3 audits to ensure proper inspection and documentation. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Fire Alarm System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain and test the fire alarm system in compliance with NFPA 70 and NFPA 72 standards. During a survey conducted on January 22, 2025, it was observed that the fire alarm panel displayed a message indicating 'Service mode, System being service, TROUBLE,' suggesting an issue with the system's operational status. Additionally, the facility was unable to provide documentation of the required two-year smoke detector sensitivity testing. These deficiencies were confirmed through an interview with the maintenance supervisor on the same day.
Plan Of Correction
A. Fire Alarm Panel "Trouble": Maintenance director immediately contacted Alti Protection to perform service on fire alarm panel and clear service mode. NHA/Designee to educate maintenance staff by 21MAR2025 on the fire control panel and service documentation. Maintenance Director/designee will audit monthly x 3. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. B. Sensitivity Test: Maintenance director obtained the 2 year sensitivity smoke detectors test from 3/25/2024.
Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to comply with sprinkler system regulations as evidenced by observations and document reviews. During a survey, it was noted that the sprinkler heads in the kitchen dishwashing area were dust-covered, dirty, and corroded. Additionally, the documentation for the third quarter sprinkler system inspection was not available at the time of the survey. An interview with the maintenance supervisor confirmed these deficiencies, indicating a lapse in the maintenance and testing of the facility's sprinkler system.
Plan Of Correction
A. Kitchen Sprinkler Heads Dust-covered maintenance cleaned kitchen sprinkler heads identified. Maintenance completed audit of whole house sprinkler heads, cleaned the sprinkler heads of dust and changed escutcheons as needed. NHA/Designee to educate maintenance staff by 21MAR2025 on importance of dust free, corrosion free sprinkler heads/escutcheons. Maintenance to complete weekly x4 audits of kitchen sprinklers. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. B. 3rd Quarter Sprinkler Documentation Maintenance immediately completed sprinkler head audit. Maintenance will maintain documentation of inspections. NHA/Designee to educate maintenance staff by 21MAR2025 on the importance of completing sprinkler maintenance and maintaining inspection documentation. NHA/designee will complete quarterly x3 documentation audit to ensure sprinkler system maintenance documentation is complete. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the quarterly audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Fire Drill Documentation Deficiency
Penalty
Summary
The facility failed to meet the fire drill requirements as evidenced by the lack of documentation for 11 out of the 12 required fire drills. The document review conducted on January 22, 2025, revealed that the facility did not have records for the first shift during the second, third, and fourth quarters, and for the second and third shifts for all four quarters. The facility explained that the documents were destroyed due to a water leak. This deficiency was confirmed during an interview with the maintenance supervisor on the same day.
Plan Of Correction
Fire Drill conducted immediately following the safety survey. No negative findings identified. NHA/designee to educate maintenance staff by 21MAR2025 on the fire drill schedule to ensure fire drills are conducted on each shift quarterly. NHA/designee will monitor the fire drills and fire drill documentation quarterly x 3 to ensure they are being done on varying shifts. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Failure to Test Electrical Receptacles Annually
Penalty
Summary
The facility failed to perform an annual test and inspection on non-hospital grade electrical receptacles in resident sleeping rooms throughout the entire facility. This deficiency was identified during a document review and interview conducted on January 22, 2025. The review revealed that electrical receptacles in resident care rooms were not tested at intervals not exceeding 12 months, as required. The testing should have included a visual inspection of physical integrity, verification of correct polarity of the hot and neutral connections, and ensuring the retention force of the grounding blade was not less than 115g (4 oz). An interview with the maintenance supervisor confirmed the lack of documentation for these tests.
Plan Of Correction
Maintenance immediately tested electrical receptacles. Maintenance to monthly testing of electrical receptacles and maintain documentation according to compliance. NHA/Designee to educate maintenance staff by 21MAR2025 about annual receptacle testing and maintaining proper documentation. NHA/designee to audit monthly x3 for electrical receptacle testing and documentation. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Failure to Maintain Emergency Generator Documentation
Penalty
Summary
The facility failed to maintain the emergency generator, which affects the entire facility. During a document review on January 22, 2025, it was revealed that the facility did not provide documentation for essential generator tests for 10 out of 12 months, specifically from March to December. The missing documentation included records of weekly visual inspections and battery voltage or electrolyte levels, as well as monthly specific gravity or conductance tests, 30-minute load runs, and transfer switch tests. The maintenance supervisor confirmed during an interview on the same day that the test documentation was unavailable at the time of the survey. The facility stated that the documents were destroyed due to a water leak, which contributed to the lack of available records. This deficiency indicates a failure to adhere to the required maintenance and testing protocols for the emergency generator, as outlined by NFPA standards.
Plan Of Correction
A. Weekly visual/inspection and battery: Maintenance initiated immediate inspection of battery and voltage test, documenting findings. Maintenance will continue to document weekly inspections. NHA/Designee will educate maintenance staff by 21MAR2025 on importance of maintaining proper documentation and electric system maintenance and testing. Maintenance director/designee will conduct weekly x4 inspections of battery and voltage test and documentation. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. B. Monthly Specific gravity or conductance 30-min load run and transfer switch. Maintenance completed 30-minute load run specific conductance test and documented results. Maintenance to conduct monthly 30-min load run tests, results to be documented and kept on file. NHA/Designee will educate maintenance staff by 21MAR2025 on requirements to do 30-min load run and transfer switch testing monthly and document results to ensure proper function and compliance. Maintenance will complete monthly x 3 audit to remain in compliance. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Failure to Maintain Emergency Preparedness Documentation
Penalty
Summary
The facility failed to maintain proper emergency preparedness guidelines as required by regulatory standards. During a document review conducted on January 22, 2025, it was discovered that the facility did not have records of conducting an annual full-scale exercise, testing, evaluating, and performing a tabletop exercise for their emergency preparedness plan. This lack of documentation indicates that the facility did not adhere to the necessary protocols to ensure readiness in the event of an emergency. The deficiency was confirmed through an interview with the maintenance supervisor on the same day. The supervisor acknowledged the absence of documentation, which further substantiates the facility's failure to comply with the emergency preparedness requirements. This oversight suggests a significant gap in the facility's ability to effectively respond to potential emergencies, as they have not demonstrated the necessary preparedness through documented exercises and evaluations. The lack of a tabletop exercise, in particular, highlights a critical area where the facility did not meet the expected standards. Tabletop exercises are essential for facilitating group discussions and problem-solving in a simulated emergency scenario, which helps in identifying potential weaknesses in the emergency plan. The absence of such exercises means that the facility has not fully tested its emergency procedures, potentially compromising the safety and well-being of its residents and staff.
Plan Of Correction
The Emergency Preparedness Plan (EPP) was reviewed and updated as necessary. The Emergency Preparedness Plan is to be reviewed and updated at least annually based on the most recent documented, facility-based and community-based risk assessment using an all-hazards approach. NHA/designee to complete annual full-scale exercise/table-top exercise by 21MAR2025. NHA/designee to educate all staff by 21MAR2025 on the EPP to ensure a comprehensive understanding of policies and procedures to ensure staff readiness. RVPO/designee to educate NHA by 21MAR2025 on the requirements of Emergency Preparedness Plan Guidelines. To prevent this from recurring, RVPO will complete annual audits on facility EPP to ensure current updated version. Negative findings will be addressed. Ad Hoc education will be provided. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendation.
Egress Discharge Deficiencies
Penalty
Summary
The facility failed to maintain the egress discharges at two of six exit discharges, as observed and confirmed during a survey. At 8:49 a.m., the exit discharge door near the time clock room was found with an exterior egress path that was not maintained and was snow-covered. Additionally, at 8:56 a.m., the exit discharge door near the employee lounge was found lacking panic or fire exit hardware. These deficiencies were confirmed through an interview with the maintenance supervisor.
Plan Of Correction
A. Discharge door not maintained: Maintenance immediately removed snow from the sidewalk from the exit discharge door near the time clock area. Maintenance completed an audit of all exit discharge doors to ensure clear egress. NHA/designee educated maintenance staff by 21MAR2025 on snow removal policy. Maintenance will complete snow removal of discharge exit doors as per policy whenever weather occurs. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. B. Discharge door failed to be equipped with panic or fire exit hardware: Maintenance replaced panic bar hardware on the exit door near the employee lounge. Maintenance completed an audit of all exit doors to ensure proper function. NHA/designee educated maintenance staff by 21MAR2025 on proper exit door function and maintenance. To prevent this from recurring, maintenance will perform weekly audits on exit door hardware/function and document. Negative findings will be addressed. Ad Hoc education will be provided. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Failure to Maintain Self-Closing Doors
Penalty
Summary
The facility failed to maintain doors with self-closing devices, as observed during a survey on January 22, 2025. Seven out of over ten doors were found to have deficiencies. Specifically, the laundry wet/dry room door did not positively latch in the frame, and the laundry wet room door was propped open. The laundry soiled utility room door failed to close and was dragging on the floor. Additionally, the kitchen door to the exterior and the kitchen dishwashing door both failed to close and latch in the frame. Furthermore, the Unit 1 fire door near resident room #127 and the Unit 2 corridor fire door also failed to latch in the frame. These deficiencies were confirmed in an interview with the maintenance supervisor.
Plan Of Correction
A. Laundry wet/dry room failed to latch: Maintenance replaced door handle to properly latch in laundry wet/dry room. Maintenance did audit of all self-closing device doors to ensure proper door latch function. NHA/designee to educate maintenance department by 21MAR2025 on the importance of ensuring door handles are operating properly. To prevent this from recurring, Maintenance will perform weekly x 4 audits on door latch function. Negative findings will be addressed. Ad Hoc education will be provided. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. B. Laundry wet room door propped open: Maintenance immediately removed the cart from the open laundry/wet room door. Maintenance did a whole house audit making sure no doors being propped open. Maintenance/designee to educate staff by 21MAR2025 on importance of not using items to hold doors open and having doors remain securely closed. To prevent this from recurring, Maintenance will perform weekly x 4 audits to ensure doors are not being propped open. Negative findings will be addressed. Ad Hoc education will be provided. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. C. Laundry soiled utility room failed to close/dragging: Maintenance adjusted laundry soiled utility room door to not drag on the floor and ensured properly closing. Maintenance completed an audit on all doors to ensure laundry soiled doors are closing properly. NHA/designee to educate maintenance staff by 21MAR2025 on importance of proper closure of all doors. To prevent this from recurring, Maintenance will perform weekly audits to ensure all doors are closing properly. Negative findings will be addressed. Ad Hoc education will be provided. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. D. Kitchen door to exterior failed to close and latch: Maintenance installed a magna lock with keypad to secure exterior kitchen door. Maintenance completed audit on all doors to ensure exterior kitchen door closed and latched properly. NHA/designee to educate maintenance staff by 21MAR2025 on importance of proper closure and latch of all exit doors. To prevent this from recurring, Maintenance will perform weekly audits to ensure proper closure and latching of doors. Negative findings will be addressed. Ad Hoc education will be provided. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. E. Kitchen dishwashing door failed to close and latch in frame: Maintenance adjusted kitchen dishwashing room door to close and latch properly. Maintenance completed audit on all doors to ensure closing and latch properly. Maintenance/designee will educate kitchen staff by 21MAR2025 on importance of ensuring proper closure and latching of all doors. To prevent this from recurring, Maintenance will perform weekly x4 audits to ensure entry and exit doors are closing and latching. Negative findings will be addressed. Ad Hoc education will be provided. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. F. Unit 1 Fire Door near #127 failed to latch in frame: Maintenance adjusted Unit 1 fire door to ensure door closed and latched properly. Maintenance completed audit on all fire doors to ensure closing and latching properly. NHA/Designee to educate maintenance staff by 21MAR2025 on importance of doors closing properly. Maintenance will do weekly x4 audit on all fire doors to ensure closing and latching properly. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. G. Unit 2 Fire Door failed to latch in frame: Maintenance adjusted Unit 2 fire door to ensure closed and latched properly. Maintenance completed audit on all fire corridor doors to ensure closing and latching properly. NHA/Designee to educate maintenance staff by 21MAR2025 on importance of doors closing properly. Maintenance will do weekly x 4 audits on all unit entry and exit fire doors to ensure closing and latching properly. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Deficiencies in Kitchen Suppression System Maintenance
Penalty
Summary
The facility failed to maintain cooking equipment in its kitchen, as evidenced by deficiencies in the kitchen suppression system. During an observation, document review, and interview, it was found that kitchen staff were uncertain about the location and operation of the hood fire suppression system's manual activation. Additionally, the facility could not provide documentation that the kitchen suppression system had been inspected twice in the previous year, as required. These deficiencies were confirmed during an interview with the maintenance supervisor.
Plan Of Correction
A. Kitchen staff uncertain of hood fire suppression Dietary Director immediately educated dietary staff on the location and proper operation of hood fire suppression system. Dietary Director/Designee to complete education to kitchen/dietary staff by 21MAR2025 to ensure certainty of location and operation of the hood fire suppression systems manual activation. Dietary Manager/Designee to complete annual educations ensuring dietary staff are aware of kitchen equipment and safety. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. B. Hood Suppression Inspection 2x in prior year. Maintenance to schedule and complete hood suppression inspection and document per maintenance schedule. Maintenance to obtain and maintain documentation and have it readily available by 21MAR2025. NHA/Designee to educate staff by 21MAR2025 on importance of completing hood suppression 2x per year and obtaining proper documentation. NHA/Designee to audit hood suppression inspection documentation monthly every 6 months. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Smoke Barrier Deficiencies Due to Ceiling Tile Issues
Penalty
Summary
The facility failed to maintain smoke barriers in over thirty rooms, affecting the entire component. During an observation conducted on January 22, 2025, between 8:45 a.m. and 10:15 a.m., it was noted that multiple ceiling tiles on the main floor were not properly maintained. These tiles were found to be loose, misaligned, damaged, or missing in various locations. Additionally, five rooms in the basement area were impacted by a recently frozen and ruptured pipe, which caused water damage to numerous ceiling tiles. The damaged tiles were removed to address the water damage and to facilitate repairs to the piping. The absence of these ceiling tiles could potentially delay the activation of fire system components and allow smoke to pass through. The maintenance supervisor confirmed these deficiencies during an interview at the time of the survey.
Plan Of Correction
Maintenance replaced damaged and deficient ceiling tiles. Maintenance completed a whole house audit to identify deficient ceiling tiles. NHA/Designee to educate maintenance staff by 21MAR2025 on the importance of ceiling tiles to ensure proper function for smoke barrier. Maintenance/designee to complete audits weekly x 4 of ceiling tiles. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. Fire Drill conducted immediately following the safety survey. No negative findings identified.
Improper Use of Electrical Power Cords
Penalty
Summary
The facility failed to maintain proper use of electrical power cords, as observed during a survey on January 22, 2025. Two specific deficiencies were noted: first, a refrigerator in the administrator's office was plugged into a power strip, which was subsequently removed during the survey. Second, a refrigerator in the soiled utility room on Unit 1 was found to be plugged into an extension cord. These observations were confirmed through an interview with the maintenance specialist, indicating non-compliance with the relevant NFPA standards regarding the use of power strips and extension cords.
Plan Of Correction
A. Refrigerator plugged into power strip in ADMIN office: Refrigerator immediately unplugged from power strip and plugged into wall; power strip removed from administrator's office. Maintenance completed whole house audit for power strip, no additional findings. NHA/Designee will be educating maintenance staff by 21MAR2025 on regulations regarding power strips. Maintenance will complete audits weekly x 4 the building for power strips, addressing negative findings immediately. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. B. Unit 1 Soiled Rm. Refrigerator plugged into extension cord: Refrigerator immediately unplugged from extension cord and plugged into wall; extension cord removed from Unit 1 soiled utility room. Maintenance completed whole house audit for extension cords, no additional findings. NHA/Designee will be educating maintenance staff by 21MAR2025 on regulations regarding extension cords. Maintenance will complete audits weekly x 4 throughout the building for extension cords, addressing negative findings immediately. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Corridor Door Latching Deficiency
Penalty
Summary
The facility failed to meet the corridor door requirements as outlined by NFPA 101 and CMS regulations. During an observation on January 22, 2025, it was noted that the door to resident room #129 did not positively latch in the frame. This deficiency was identified as a failure to comply with the requirement that corridor doors must resist the passage of smoke and have positive latching hardware, especially in fully sprinklered smoke compartments. The maintenance supervisor confirmed the deficiency during an interview conducted at the same time as the observation. The report does not provide additional details about the resident in room #129 or any specific medical history or condition. The focus of the deficiency is on the physical infrastructure of the facility, specifically the corridor door's inability to latch properly, which is a critical component of fire safety and smoke containment in the facility.
Plan Of Correction
Maintenance immediately adjusted room 129 door to ensure closure and latch properly. Maintenance audited all resident doors to ensure doors were operating correctly. Maintenance director/designee to educate maintenance staff by 21MAR2025 on importance of proper door closure. Maintenance Director/designee will do weekly x4 audit of all resident room doors to make sure that doors are closing and latching correctly. Negative findings will be addressed accordingly. Ad Hoc education as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 279 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Kittanning
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Armstrong Rehabilitation And Nursing Center | 2.8 mi | ★★★★★ | 64 | 1 |
| Snu Armstrong Co Memorial Hosp | 3.4 mi | ★★★★★ | 0 | 0 |
| Quality Life Services - Sarver | 12 mi | ★★★★★ | 16 | 0 |
| Quality Life Services - Sugar Creek | 12.8 mi | ★★★★★ | 4 | 1 |
| Concordia Lutheran Health And Human Care | 16.5 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 July 2026) and official state health department websites.