Kinzua Nursing and Rehab

In the surveyor’s words

From the most serious findings on record at Kinzua Nursing and Rehab, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Feb 26, 2026

  Based on review of the Pennsylvania Code Title 49. Professional and Vocational Standards, facility policies, facility job description, clinical records, and staff interviews, it was determined that the facility failed to follow nursing standards of practice to ensure admission medications are transcribed accurately for one of one residents reviewed (Resident R1). The facility's failure created a situation which placed the residents in Immediate Jeopardy of the likelihood of serious bodily injury, harm, or death for Resident R1.Findings include: Review of Pennsylvania Code Title 49. Professional and Vocational Standards 21.11. […]

• No harm, potential for more than minimal, widespreadF801Mar 24, 2025

  Based on review of employee credentials, and staff interviews, it was determined that the facility failed to ensure the employee designated as the full-time director of food and nutrition services, who was not a qualified dietitian or other clinically qualified nutritional professional, received frequently scheduled consultations from a qualified dietitian and/or failed to employ a full-time qualified dietitian since 1/7/25. Findings include: Review of the employee file/credentials the facility designated as the director of food and nutrition services revealed that he/she lacked the appropriate competencies and skills to function as the director to include any of the following: a certification for food service manager or a similar national certification for food service management and… […]

• No harm, potential for more than minimal, patternF842Sep 5, 2025

  Based on review of facility policies and clinical records and staff interviews, it was determined that the facility failed to maintain accurate and complete documentation for four of twelve residents reviewed (Residents R2, R3, R7 and R11) Findings include: Review of facility policy entitled Death of a Resident, Documentation, dated [DATE], indicated appropriate documentation shall be made in the clinical records concerning the death of a resident and that all information pertaining to a resident's death (i.e. date, time of death, name and title of individual pronouncing the resident dead, etc.) must be recorded in the nurse's notes. The policy further stated that the name of the mortician and person removing the deceased resident must be entered into the resident's medical record. […]

• No harm, potential for more than minimal, patternF692Mar 24, 2025

  Based on review of facility policy, job description, and clinical records, and staff interviews, it was determined that the facility failed to accurately and consistently assess a resident's nutritional status on admission and as needed thereafter and failed to complete a comprehensive nutritional assessment on a resident identified as being at risk for unplanned weight loss and/or compromised nutritional status for 27 of 85 Residents reviewed (Residents R1, R10, R11, R15, R20, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, R37, R38, R39, R40, R41, R42, and R43) Findings include: Review of facility policy dated 12/2/24, entitled Nutritional Management revealed the facility provides care and services to each resident to ensure the resident maintains acceptable… […]

• No harm, potential for more than minimal, patternF578Dec 5, 2024

  Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to comprehensively address the formulation of advance directives (legal instructions regarding your preferences for medical care if you are unable to make decisions for yourself-to include information provided oral and/or written instructions about future medical care in the event of becoming unable to express medical wishes) for two of 24 residents reviewed (Residents R4 and R36). […]