Armstrong Rehab: Wandering Resident Care Plan Failure - PA
Nothing else. Nothing specific to the resident.
The finding emerged from a complaint inspection completed August 18, 2025. Inspectors reviewed clinical records for six residents the facility had identified as high risk for wandering or elopement. One of them, identified in inspection records only as Resident R1, had a care plan that named the wandering behavior but offered no interventions tied to who that resident actually was, what triggered the wandering, or what had worked or failed before.
The facility's own elopement and wandering policy, dated July 1, 2025, stated that residents who wander must receive care that addresses "the unique factors contributing to wandering or elopement risk." It said the facility would implement interventions specific to each resident and modify them when necessary.
Resident R1's care plan did neither.
The resident had been assessed using the Brief Interview for Mental Status, a standardized screening tool that scores cognitive function on a scale of zero to fifteen. A score between eight and twelve indicates moderate impairment. Resident R1 scored a twelve. The resident also carried diagnoses of anxiety and muscle weakness, and an elopement evaluation completed July 22, 2025 recorded that the resident wanders through the facility or prior residence, though not beyond interior settings. The elopement risk score came back at thirteen, placing the resident in a category that warranted active, individualized planning.
The care plan was revised that same day, July 22. The three generic interventions were what the revision produced.
Person-centered care planning in a nursing home context means something specific: it means the plan reflects the individual, not the diagnosis category. A resident who wanders because of anxiety is different from a resident who wanders because of disorientation about where they are. A resident who wanders toward exits at certain times of day is different from one who drifts through hallways. The triggers matter. The history matters. The interventions that have actually worked for that person matter. A care plan that doesn't contain any of that information isn't a care plan in any meaningful sense. It's a placeholder.
When inspectors interviewed the Director of Nursing on August 18, at 1:46 in the afternoon, the director confirmed the failure outright. The facility had not ensured that Resident R1 had a person-centered care plan individualized to the resident's specific needs.
Armstrong Rehabilitation and Nursing Center sits at 265 South McKean Street in Kittanning, in western Pennsylvania's Armstrong County. The deficiency was cited at a level of minimal harm or potential for actual harm, affecting a small number of residents. That designation reflects what inspectors documented at the time of the visit. It does not account for what might happen on an ordinary evening when a cognitively impaired resident, anxious and physically weakened, decides to move through the building with no plan in place designed around the specific reasons that resident moves.
The facility's own policy acknowledged that wandering residents face accident risk and that supervision must be adequate. A care plan built entirely around the possibility of future medication or future referrals to psychiatry or psychology provides no guidance to the certified nursing assistant working the overnight shift, or the floor nurse trying to redirect a resident who has been found near a stairwell at two in the morning.
What that staff member has, in place of a real plan, is three lines that offer nothing actionable.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Armstrong Rehabilitation and Nursing Center from 2025-08-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 5, 2026 · Our methodology
ARMSTRONG REHABILITATION AND NURSING CENTER in KITTANNING, PA was cited for violations during a health inspection on August 18, 2025.
Nothing specific to the resident.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.