Kinzua Nursing and Rehab

Inspectors wroteBased on review of facility policy, clinical records, and facility documents, and staff interview it was determined that the facility failed to provide care and treatment according to the resident's comprehensive person-centered care plan, and address provider recommendations for psychiatric medication changes for one of four residents reviewed (Resident R2).

Inspectors wroteBased on review of the Pennsylvania Code Title 49. Professional and Vocational Standards, facility policies, facility job description, clinical records, and staff interviews, it was determined that the facility failed to follow nursing standards of practice to ensure admission medications are transcribed accurately for one of one residents reviewed (Resident R1). The facility's failure created a situation which placed the residents in Immediate Jeopardy of the likelihood of serious bodily injury, harm, or death for Resident R1.

Inspectors wroteBased on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to prevent significant medication errors for one resident receiving a psychotic (mind altering) medication (Resident R1).

Inspectors wroteBased on review of facility records and job descriptions, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to make certain that admission medications are transcribed accurately.

Inspectors wroteBased on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure physician orders, residents' Physician Order for Life Sustaining Treatment (POLST- a legal document specifying the resident/responsible party choices regarding life-sustaining treatments), electronic health record (EHR), and paper charts were consistent for two of 18 residents reviewed (Residents R9 and R52).

Inspectors wroteBased on review of the Minimum Data Set (MDS-periodic assessment of resident care needs) User's Manual, clinical record, and staff interview, it was determined that the facility failed to complete a comprehensive assessment after a significant change in condition for one of two residents reviewed receiving hospice services (Resident R49).

Inspectors wroteBased on review of facility policy, observation, and staff interview, it was determined that the facility failed to utilize infection control practices regarding Enhanced Barrier Precautions (EBPs-additional infection control precautions put in place for individuals who have an increased risk of multi-drug resident organisms [MDROs] or who are colonized/infected with MDROs) for wound care for one of 18 residents reviewed (Resident R12).

Inspectors wroteBased on review of facility policies and clinical records and staff interviews, it was determined that the facility failed to maintain accurate and complete documentation for four of twelve residents reviewed (Residents R2, R3, R7 and R11)

Inspectors wroteBased on review of facility policies, clinical records, resident and staff interview, it was determined that the facility failed to provide a bath/shower per resident preference and failed to ensure that residents received assistance with bathing for two of 12 residents reviewed (Residents R3 and R4). Review of facility policy entitled Bed Bath, Shower/Tub dated 12/2/24, indicated The purpose of this procedure are to promote cleanliness, provide comfort to the resident. and Documentation 1. The date and time the shower/tub or bed bath was performed. 2. The name and title of the individual(s) who assisted the resident with the shower/tub or bed bath. Review of Resident R3's clinical record revealed an admission date of 4/4/25, with diagnoses that included chronic obstructive pulmonary disease (when your lungs do not have adequate air flow) and hypertension (high blood pressure). [...]

Inspectors wroteBased on review of facility policies, clinical records and staff interviews, it was determined that the facility failed to take appropriate timely action to obtain a medication for one of 12 residents reviewed (Resident R1). Review of a facility policy entitled Administering Medication dated 12/2/24, indicated medications are administered in a safe and timely manner, as prescribed. Review of a facility policy entitled Medications Ordering and Receiving from Pharmacy dated 12/2/24, indicated medications and related products are received from the dispensing pharmacy on a timely basis. Review of facility policy entitled Medication orders dated 12/2/24, indicated a verbal prescription for a scheduled II medication may be called in to a pharmacist directly by the prescriber. The supply can be delivered from the pharmacy or may be available from the emergency kit. [...]

Inspectors wroteBased on review of facility policy and clinical record review and staff interview, it was determined that the facility failed to ensure that medication was obtained and provided as ordered by the physician for one of 12 residents reviewed (Resident R2). Review of facility policy entitled Administering Medications dated 12/2/24, indicated Medications are administered in accordance with prescriber orders, including any required time frame. Review of facility policy entitled Medication Orders dated 12/2/24, indicated The prescriber is contacted by nursing for directions when delivery of a medication will be delayed, or the medication is not or will not be available. [...]

Inspectors wroteBased on review of employee credentials, and staff interviews, it was determined that the facility failed to ensure the employee designated as the full-time director of food and nutrition services, who was not a qualified dietitian or other clinically qualified nutritional professional, received frequently scheduled consultations from a qualified dietitian and/or failed to employ a full-time qualified dietitian since 1/7/25.

Inspectors wroteBased on review of facility policy, job description, and clinical records, and staff interviews, it was determined that the facility failed to accurately and consistently assess a resident's nutritional status on admission and as needed thereafter and failed to complete a comprehensive nutritional assessment on a resident identified as being at risk for unplanned weight loss and/or compromised nutritional status for 27 of 85 Residents reviewed (Residents R1, R10, R11, R15, R20, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, R37, R38, R39, R40, R41, R42, and R43)

Inspectors wroteBased on review of facility policies and clinical records, and staff interview, it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold (explanation of how long a bed can be held during a leave of absence and the cost per day) upon or within twenty-four hours of transfer for two of two residents reviewed for hospitalizations (Residents R11 and R12).

Inspectors wroteBased on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of 15 Residents reviewed (Resident R1).

Inspectors wroteBased on review of facility policy and clinical records and staff interview, it was determined that the facility failed to review and/or revise resident care plans for seven of 15 residents reviewed (Residents R9, R10, R8, R15, R16, R20, and R22).

Inspectors wroteBased on review of clinical records, facility policies and documentation, and staff interview, it was determined that the facility failed to ensure adequate safety measures were implemented related to wheelchair transport and fall precautions for two of four residents reviewed for falls (Residents R13 and R14).

Inspectors wroteBased on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to comprehensively address the formulation of advance directives (legal instructions regarding your preferences for medical care if you are unable to make decisions for yourself-to include information provided oral and/or written instructions about future medical care in the event of becoming unable to express medical wishes) for two of 24 residents reviewed (Residents R4 and R36).

Inspectors wroteBased on review of clinical records, observations, and staff interviews, it was determined that the facility failed to ensure physician's orders were followed for three of 24 residents reviewed (Residents R17, Resident R65, and Resident R69).

Inspectors wroteBased on review of facility policy and clinical records, observations, and staff interviews, it was determined that the facility failed to ensure that a resident with limited range of motion received treatment and services to prevent further decrease in range of motion for one of two residents reviewed for range of motion (Resident R65).

Inspectors wroteBased on review of facility policies and clinical records, observations, and staff interviews, it was determined that the facility failed to provide appropriate care regarding a urinary catheter (a tube inserted into the bladder to drain urine into a bag) for three of five residents reviewed for catheters (Residents R1, R5, and R11)

Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to label multi-dose containers of insulin (medication to treat elevated blood sugar levels) with the date they were opened and discard an opened multi-dose vial of insulin in a timely manner in two of three medication carts (Gold and Red Units) and discard an opened multi-dose vial of Tuberculin solution (solution used to test for the disease tuberculosis) in one of three medication storage rooms (Red Unit).

Inspectors wroteBased on review of facility policies, observations, and staff interview, it was determined that the facility failed to maintain sanitary operations and standards for food safety in the main kitchen and in one pantry reviewed (Gold Pantry).

Inspectors wroteBased on observations, review of facility policies and documents, and staff, resident, and visitor interviews, it was determined that the facility failed to provide housekeeping services necessary to maintain a clean environment in one resident room (520) and clean equipment for one resident (Resident R37).

Inspectors wroteBased on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to obtain a physician's order for the provision of oxygen therapy for one of one residents reviewed for respiratory services (Resident R26).

Inspectors wroteBased on review of facility policy, observations, and staff interview, it was determined that the facility failed to maintain a clean and sanitary resident shower room in one of two shower rooms (Red shower room).

Inspectors wroteBased on review of facility policy and clinical record, and staff interview, it was determined that the facility failed to notify the resident's responsible party of a change in condition for one of five residents reviewed (Resident R1).

Inspectors wroteBased on review of facility policy, clinical records, observations, and resident and staff interviews it was determined that the facility failed to promote self-determination through the support of resident choices about aspects of their lives that were identified as important for five of 24 residents reviewed (Residents R14, R37, R40, R82, and R186).

Inspectors wroteBased on review of a facility policy, observations, and staff interview, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety in one of three stand up refrigerators and one of one dry storage areas reviewed in the kitchen.

Inspectors wroteBased on review of facility policy and clinical records, and staff and resident interviews, it was determined that the facility failed to ensure that the resident was offered the opportunity to participate in the development, review, and/or revision of their person-centered care plan for two of 24 residents reviewed (Residents R29 and R73).

Inspectors wroteBased on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day) upon transfer for two of 24 residents reviewed (Residents R8 and R19).

Inspectors wroteBased on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to review and revise comprehensive care plans timely and to reflect the current necessary care and services for one of 24 residents reviewed (Resident R66).

Inspectors wroteBased on review of facility policy and clinical records, observation, and resident and staff interview, it was determined that the facility failed to obtain a physician's order for the provision of oxygen therapy for one of one residents reviewed for respiratory services (Resident R286).

Inspectors wroteBased on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to implement all safety measures related to following all care planned fall precautions for one of eight residents reviewed (Resident R1).