Kinzua Nursing And Rehab
KINZUA NURSING AND REHAB in WARREN, PA — inspection on February 26, 2026.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of a neurology progress note dated 2/10/26, revealed that Resident R1's lithium doses were not correctly dosed and that Resident R1was showing signs of active psychosis.
that Resident R1 was sent to an appointment on 2/10/26, and has not returned to the facility.
During interviews on 2/25/26, between 11:35 a.m. and 12:55 p.m. the Director of Nursing (DON) confirmed that Resident R1 had been having flight of thoughts and increased behaviors.
The DON confirmed that Resident R1's order for lithium carbonate 300 mg was not transcribed from his/her transfer orders into his/her facility medication record. He/she confirmed that Resident R1's pharmacy admission medication review dated 1/8/26, indicating a potential clinically significant irregularity for resident R1's lithium carbonate order was identified and not addressed by the facility staff and/or physician.
He/she also confirmed that the lithium carbonate 300 mg order should have been clarified by the physician and transcribed into Resident R1's medication record, and that the pharmacy medication review should have been addressed by the facility and physician. On 2/25/26, at 2:37 p.m. the Nursing Home Administrator (NHA) and DON were made aware that Immediate Jeopardy (IJ) existed for in the facility and that a corrective action plan was required.
The IJ template was provided to the NHA at that time. On 2/25/26, at 5:28 p.m. an acceptable immediate action plan was approved which included the following interventions: All Registered Nurses will receive education regarding the proper process for entering physician orders for new admissions.
Which will include thorough review of hospital discharge orders, accurate entry of orders into the electronic health record, and the required process for transcription and clarification to ensure accuracy within the medical record.
Nursing staff will utilize a standard Medication Transcription/Clarification Tool during the admission process to ensure all medication orders are completely and accurately transcribed.
Any discrepancies identified will be clarified with the physician prior to implementation, and physicians will be notified promptly of any transcription error or clarification needs.
Implementing a revised admission process requiring use of the Medication Transcription/Clarification Tool to validate that medication orders are accurately entered into electronic health record and appropriately populate in the electronic medication administration record.
Director of Nursing or designee will audit the last 30 days of admissions as well as any new admissions moving forward within 48 hours to verify accuracy of order transcription and clarification. admission audits will be conducted three times a week until sustained compliance is achieved.
Audit results will be reviewed at the Quality Assurance Performance Improvement meetings and additional corrective action or re-education will be implemented as indicated by audit findings. On 2/26/26, between 10:30 a.m. and 12:24 p.m. review of staff education, medication transcription/clarification tool, audits of physician orders for new admissions in the past 48 hours and past 30 days, and staff interviews confirmed the facility implemented the above stated action plan. On 2/26/26, at 12:53 p.m. NHA and DON were informed that the Immediate Jeopardy had been lifted. 28 Pa.
Code 201.14(a) Responsibility of licensee 28 Pa.
Code 201.18(b)(1) Management 28 Pa.
Code 211.12(c)(d)(1)(5)(3) Nursing services 28 Pa.
Code 211.9(a)(1) Pharmacy services
395363 02/26/2026
Kinzua Nursing and Rehab 205 Water Street Warren, PA 16365
Review of a facility policy entitled Medication and Treatment Orders dated 12/9/25, indicated Clarify the order and transcribe newly prescribed medications. on the Medication Administration Record (MAR). record or ensure the order is in the electronic MAR. and Written transfer orders (sent with a resident by hospital or other health care facility)-Implement a transfer order. unless the order is unclear or incomplete. the receiving nurse should verify the order with the current attending physician.
Review of a facility policy entitled Medication Errors dated 12/9/25, indicated the facility shall ensure medications will be administered. according to physician orders.
Review of Resident R1's clinical record revealed an admission date of 1/8/26, with diagnoses that included schizoaffective disorder bipolar type (a mental illness that causes impaired thinking process with episodes of extreme mood swings with emotional highs and emotional lows), Parkinson's (a chronic and progressive movement disorder that causes shaking, slows a person's ability to move and worsens over time), and major depressive disorder (a serious mood disorder that causes feelings of sadness, loss of interest in daily activities, emotional and physical problems that impact daily life).
Review of Resident R1's facility physician orders (orders that are transcribed by the facility into the resident's electronic medical record) dated 1/8/26, lacked evidence of an order for lithium 300 mg tablet extended release orally, therefore Resident R1 did not receive the lithium carbonate 300 mg from 1/8/26, through 2/8/26.
During an interview on 2/25/26, at 11:57 a.m. the Director of Nursing (DON) confirmed that Resident R1's order for lithium carbonate 300 mg was not transcribed from his/her transfer orders into his/her medication record and subsequently Resident R1 was not administered the ordered medication. He/she also confirmed that the lithium carbonate 300 mg order should have been clarified by the physician and transcribed into Resident R1's medication record to ensure administration. 28 Pa.
Code 211.12(d)(1)(3)(5) Nursing services
395363 02/26/2026
Kinzua Nursing and Rehab 205 Water Street Warren, PA 16365
Based on the findings in this report that identified the facility failed to make certain that admission medications are transcribed accurately, the NHA and the DON failed to fulfill their essential job duties to ensure that the Federal and State guidelines and Regulations were followed. 28 Pa.
Code 201.14(a) Responsibility of Licensee 28 Pa.
Code 201.18(b)(1)(3)(e)(1) Management 28 Pa.
Code 211.12(d)(1)(3)(5) Nursing Services