Kinzua Nursing and Rehab: Wound Care Records Gaps - PA
Inspectors reviewed the August Treatment Administration Records for three residents during a complaint inspection completed September 5, 2025. What they found was a pattern of incomplete documentation across every wound care order on file, for every resident they examined.
One resident, identified in the report as R2, had four separate wound treatment orders active during the month. The first required staff to cleanse a left buttock wound with wound cleanser, pat it dry, and apply Medihoney covered with border gauze. Out of 20 chances to document that the treatment was done, staff completed the entry four times. Sixteen were left blank.
A second order for R2, dated later in the month, called for cleansing the left buttock with wound cleanser, patting dry, and applying Medihoney with border gauze. Out of four opportunities to document completion, one was filled in. Three were blank. A third order directed staff to cleanse both buttocks, apply a thin layer of Triad wound treatment to areas of excoriation, and leave the skin open to air every shift. Out of 20 documentation opportunities, five were left blank. A fourth order, requiring staff to cleanse a left buttock wound, pack a tunnel with iodoform, apply calcium alginate across the entire open area, and cover with border gauze every day shift, had five documentation opportunities. One was completed. Four were blank.
The second resident, R7, does not appear separately detailed in the portion of the report available, but the director of nursing confirmed R7's records were also incomplete.
The third resident, R11, arrived at the facility with a pressure ulcer on the right heel, adult failure to thrive, protein calorie malnutrition, and bipolar disorder. Three treatment orders were active for R11 in August. The first required daily cleansing of a coccyx pressure ulcer, application of Medihoney, and covering with an Optifoam dressing every day shift. Out of 27 opportunities to document completion, 16 were filled in. Eleven were blank. The second order called for weekly weights, recorded every seven days. Out of four opportunities, one was documented. Three were blank. The third order directed staff to cleanse the right heel wound, cover it with betadine gauze, and apply a bordered gauze dressing every day shift. Out of 19 opportunities, 10 were documented. Nine were blank.
The director of nursing, interviewed at 1:25 p.m. on the day of the inspection, confirmed that the clinical records for all three residents were incomplete.
What the records cannot answer is the question that matters most: whether the treatments were skipped, or simply never written down. A blank line in a treatment administration record means one of two things, and neither is acceptable. Either a nurse or aide performed the wound care and failed to document it, which is its own serious lapse in a facility caring for people with open, tunneling, and infected wounds. Or the treatment was not performed at all.
For a resident like R11, admitted with a heel pressure ulcer and documented malnutrition, missed wound care and missed weekly weights are not paperwork problems. Pressure ulcers can deepen and become infected without consistent treatment. Weights track whether a malnourished resident is stabilizing or declining. When the records are blank, nobody knows.
The same logic applies to R2's wounds. Tunneling wounds, the kind that require packing with iodoform, are among the more serious wound presentations in long-term care. They require precise, consistent treatment. Out of five chances to document that the packing was done, staff recorded it once.
The facility was cited under Pennsylvania regulations governing medical records and nursing services. The violation was classified as causing minimal harm or potential for actual harm, affecting some residents.
The director of nursing did not dispute what the records showed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Kinzua Nursing and Rehab from 2025-09-05 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: June 30, 2026 · Our methodology
KINZUA NURSING AND REHAB in WARREN, PA was cited for violations during a health inspection on September 5, 2025.
Inspectors reviewed the August Treatment Administration Records for three residents during a complaint inspection completed September 5, 2025.
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.