Kittanning Health & Rehab Center

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

shift11/7/25, 11 p.m. - 7 a.m. shift11/10/25, 11 p.m. - 7 a.m. shift11/15/25, 11 p.m. - 7 a.m. shift11/17/25, 11 p.m. - 7 a.m. shift During an interview on 11/18/25, at 11:54 a.m. LPN Employee E2 confirmed the above

observations and stated, It's mostly night shift that forgets to sign. Review of the clinical record indicated Resident Resident R1 was admitted to the facility on [DATE REDACTED]. Review of Resident Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/4/25, indicated diagnoses of anxiety, depression, and history of falling. Review of a physician order dated 1/21/25, indicated to administer lorazepam (a schedule IV medication given to treat anxiety) 0.5 milligrams by mouth three times a day. Review of a progress note dated 9/22/25, stated, At 1420 (2:20 p.m.) LPN notified this nurse that resident's lorazepam was signed out at 0700 (7 a.m.), then given again at 1000 (10 a.m.). This nurse notified RN (Registered Nurse) Supervisor of medication error. Physician notified, resident representative notified. Resident does not appear to have any side/adverse effects. Review of a progress note dated 9/22/25, stated, Potential medication error due to no report from midnight shift nurse giving unscheduled medication. No report of PRN given either. Also no documentation of medication in electronic medical record. RN Sup (Supervisor) made aware, incident report completed. Review of a witness statement dated 9/23/25, completed by LPN Employee E6 stated, At 1430 (2:30 p.m.) LPN Employee E3 brought the red narcotic book from Unit 2A to this nurse stating that the night shift nurse gave the resident her AM (morning) Ativan (lorazepam) and signed it out at 0700. LPN Employee E3 proceeded to tell this nurse that she also gave Resident Resident R1 her AM Ativan at 1000. LPN Employee E3 stated that she did not notice until the end of the shift because she doesn't sign her narcotics out until her shift is over. Review of a witness statement dated 9/23/25, completed by LPN Employee E3 stated, During count at 0715-0730 (7:15 a.m. - 7:30 a.m.) with LPN Employee E4, there was a medication card that was counted only #23 Ativans. When LPN Employee E4 said #23, nurse stated No there are #22.

LPN Employee E4 then signed her name in the narc book and signed out the medication. Nurse (I) assumed she had given the medication and just forgot to sign it out making the count add up. During report LPN Employee E4 stated that the residents were good. There was no COVID resident. She also stated it was a crazy night and she is never coming back to this facility. Then she left. Review of a witness statement dated 9/25/25, completed by LPN Employee E4 stated, 0600 (6 a.m.) giving morning meds and signed out Ativan for 0700 (7 a.m.) was due at 0800 (8 a.m.). Unsure if I gave it or what happened to it.Review of Resident Resident R1's Individual Narcotic Log sheet for Ativan 0.5 mg revealed the medication was signed out as administered on 9/22/25, at 0700 by LPN Employee E4 and signed out as administered on 9/22/25, at 1000 by LPN Employee E3. During an interview on 11/18/25, at 2:17 p.m. the Nursing Home Administrator confirmed that the facility failed to implement procedures to promote accurate accounting of controlled medications on two of two medication carts and failed to ensure accurate administration of medications, resulting in a medication error for one of five residents (Resident Resident R1). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(c) Resident care policies.28 Pa. Code: 211.12 (d)(1)(5) Nursing services.28 Pa. Code: 211.19(a)(1)(k) Pharmacy services.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Kittanning Health & Rehab Center

120 Kittanning Care Drive Kittanning, PA 16201

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

chlordiazepoxide (Librium - a schedule IV medication given to treat anxiety) 10 mg by mouth once a day in

the morning. Review of a physician order dated 4/5/25, indicated to administer chlordiazepoxide 5 mg by mouth once a day at bedtime.Review of a progress note dated 10/2/25, stated, This writer alerted to questionable med error on 9/29 and 9/30. After review it is noted that original orders are Librium 10 mg q (every) day and Librium 5 mg q hs (night). Resident has been given Librium 10 mg at hs on the 29/30 of September. CRNP (Certified Registered Nurse Practitioner) and resident representative have been notified of incident. Resident has had no adverse reactions to the error. During an interview on 11/18/25, at 2:17 p.m. the Nursing Home Administrator confirmed that the facility failed to ensure that residents are free of significant medication errors for two of three residents reviewed (Residents Resident R1 and Resident R2). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1) Management.28 Pa. Code: 211.10 (c) Resident Care policies.28 Pa. Code: 211.12 (d)(1)(5) Nursing services.

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