Kittanning Health & Rehab: Medication Errors Found - PA
The drug was chlordiazepoxide, sold under the brand name Librium, a Schedule IV controlled substance used to treat anxiety. The resident had two separate orders for it: 10 milligrams in the morning, and 5 milligrams at bedtime. On the nights of September 29 and 30, staff gave the 10-milligram dose at bedtime instead of the 5-milligram dose.
A progress note dated October 2 recorded how the discovery unfolded. "This writer alerted to questionable med error on 9/29 and 9/30," the note read. "After review it is noted that original orders are Librium 10 mg q day and Librium 5 mg q hs. Resident has been given Librium 10 mg at hs on the 29/30 of September."
The note confirmed that the facility's nurse practitioner and the resident's representative were notified. It also noted the resident had no adverse reactions.
That last detail is not a defense. It is luck.
Chlordiazepoxide is a benzodiazepine, a class of drugs that slow the central nervous system. In elderly residents, even small dose increases carry real risk: sedation, confusion, falls, breathing problems. The difference between 5 milligrams and 10 milligrams at bedtime, in a nursing home resident, is not a rounding error. It is a doubling of the intended nighttime dose of a drug that depresses the brain.
The errors were not discovered through any internal medication audit or nursing review at the time they happened. The progress note, written three days after the second error, describes someone being "alerted" to a "questionable med error" — language that suggests the problem surfaced by chance rather than by system.
When federal inspectors arrived at Kittanning Health & Rehab on November 18, the medication error record was part of what they reviewed. What they found was not limited to a single resident. The facility's own administrator, interviewed that afternoon at 2:17 p.m., confirmed that the facility had failed to ensure residents were free of significant medication errors for two of the three residents whose records inspectors examined.
Two out of three.
The inspection was a complaint survey, meaning someone had already raised concerns before inspectors walked through the door. The medication error findings fell under federal tag F0760, which addresses significant medication errors, and were cited at a level of minimal harm or potential for actual harm, affecting a few residents.
Kittanning Health & Rehab is located in Kittanning, the county seat of Armstrong County in western Pennsylvania. The November inspection covered four pages of findings, with the medication error citation appearing on the final page.
The facility's administrator did not dispute the finding. The confirmation came directly, on the record, during the inspection interview.
What the October 2 progress note does not explain is how the same error happened on two consecutive nights. A single wrong administration could reflect one nurse's mistake on one shift. Two nights in a row suggests something more: a pattern in how the medication was set up in the system, how the order was transcribed, or how the medication administration record was read. The inspection report does not answer that question. The facility has not said publicly what it found when it looked.
The resident, according to the available record, did not suffer visible harm. But the resident also received a controlled substance at twice the intended bedtime dose for two nights running before anyone noticed.
That is what the record shows.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Kittanning Health & Rehab Center from 2025-11-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 1, 2026 · Our methodology
KITTANNING HEALTH & REHAB CENTER in KITTANNING, PA was cited for violations during a health inspection on November 18, 2025.
The drug was chlordiazepoxide, sold under the brand name Librium, a Schedule IV controlled substance used to treat anxiety.
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.