Health inspection·April 29, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to ensure the physician was appropriately notified of missed medication doses for one of five residents reviewed (Resident R1). Findings include: Review of facility policy Medication Shortages/Unavailable Medications dated 1/12/25, indicated upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from pharmacy. If the medication is unavailable from pharmacy or a third-party pharmacy, and cannot be supplied from the manufacturer, facility should obtain alternate physician/prescriber orders, as necessary. Review of facility policy Resident Change in Condition dated 1/12/25, indicated the physician/provider and resident/family/responsible party will be notified when there has been a need to alter the resident's medical treatment, including a change in provider orders. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/19/25, indicated diagnoses of high blood pressure, depression, and personal history of malignant neoplasm of prostate (prostate cancer). Review of a physician order dated 3/11/25, indicated to administer Nubeqa (a medication given to decrease growth and spread of prostate cancer) 600 milligrams by mouth twice a day. Review of Resident R1's April 2025 Medication Administration Record revealed the scheduled medication was not administered on the following: - 4/21/25 PM Med Pass, the documented reason was Drug/Item Unavailable: medication was reordered has not arrived - 4/22/25 AM Med Pass, the documented reason was Not Administered: Refused - 4/22/25 PM Med Pass, the documented reason was Drug/Item Unavailable: family is to provide - 4/23/25 AM Med Pass, the documented reason was Drug/Item Unavailable Page 1 of 6 395986 395986 04/29/2025 Kittanning Health & Rehab Center 120 Kittanning Care Drive Kittanning, PA 16201

F 0580 - 4/23/25 PM Med Pass, the documented reason was Drug/Item Unavailable Level of Harm - Minimal harm or potential for actual harm - 4/24/25 AM Med Pass, the documented reason was Drug/Item Unavailable - 4/24/25 PM Med Pass, the documented reason was Drug/Item Unavailable: family to supply Residents Affected - Few - 4/25/25 AM Med Pass, the documented reason was Drug/Item Unavailable - 4/25/25 PM Med Pass, the documented reason was Drug/Item Unavailable - 4/26/25 AM Med Pass, the documented reason was Drug/Item Unavailable - 4/26/25 PM Med Pass, the documented reason was Drug/Item Unavailable - 4/27/25 AM Med Pass, the documented reason was Drug/Item Unavailable - 4/27/25 PM Med Pass, the documented reason was Drug/Item Unavailable - 4/28/25 AM Med Pass, the documented reason was Drug/Item Unavailable - 4/28/25 PM Med Pass, the documented reason was Drug/Item Unavailable - 4/29/25 AM Med Pass, the documented reason was Drug/Item Unavailable: supplied by family; awaiting arrival During an interview on 4/29/25, at 9:56 a.m. the Director of Nursing (DON) stated, Resident R1 was admitted in 2023 on this cancer medication. He's his own person, but he has a brother involved. This cancer medication is $1500 a month, his brother pays out of pocket for it. We recently found out that this brother is now unable to order and provide the medication. He got it from a pharmacy in Delaware. He has another brother who is willing to take over and supply the medication, however since Resident R1 is his own person and responsible party, we can't give the other brother any of his medication information without his permission and Resident R1 has stated he doesn't want us to talk to his brother. During an interview on 4/29/25, at 10:41 a.m. the DON stated the facility was unable to provide documentation that the physician was made aware of Resident R1's medication being unavailable and that the facility failed to ensure the physician was appropriately notified of missed medication doses for Resident R1. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1) Management. 28 Pa. Code: 211.10 (c)(d) Resident Care policies. 28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services. 395986 Page 2 of 6 395986 04/29/2025 Kittanning Health & Rehab Center 120 Kittanning Care Drive Kittanning, PA 16201

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policy, clinical record, and staff interview, it was determined that the facility failed to provide medications as ordered by the physician for one of five residents (Resident R1). Residents Affected - Few Findings include: Review of facility policy Medication Shortages/Unavailable Medications dated 1/12/25, indicated upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from pharmacy. If the medication is unavailable from pharmacy or a third-party pharmacy, and cannot be supplied from the manufacturer, facility should obtain alternate physician/prescriber orders, as necessary. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/19/25, indicated diagnoses of high blood pressure, depression, and personal history of malignant neoplasm of prostate (prostate cancer). Review of a physician order dated 3/11/25, indicated to administer Nubeqa (a medication given to decrease growth and spread of prostate cancer) 600 milligrams by mouth twice a day. Review of Resident R1's April 2025 Medication Administration Record revealed the scheduled medication was not administered on the following: - 4/21/25 PM Med Pass, the documented reason was Drug/Item Unavailable: medication was reordered has not arrived - 4/22/25 AM Med Pass, the documented reason was Not Administered: Refused - 4/22/25 PM Med Pass, the documented reason was Drug/Item Unavailable: family is to provide - 4/23/25 AM Med Pass, the documented reason was Drug/Item Unavailable - 4/23/25 PM Med Pass, the documented reason was Drug/Item Unavailable - 4/24/25 AM Med Pass, the documented reason was Drug/Item Unavailable - 4/24/25 PM Med Pass, the documented reason was Drug/Item Unavailable: family to supply - 4/25/25 AM Med Pass, the documented reason was Drug/Item Unavailable - 4/25/25 PM Med Pass, the documented reason was Drug/Item Unavailable - 4/26/25 AM Med Pass, the documented reason was Drug/Item Unavailable - 4/26/25 PM Med Pass, the documented reason was Drug/Item Unavailable 395986 Page 3 of 6 395986 04/29/2025 Kittanning Health & Rehab Center 120 Kittanning Care Drive Kittanning, PA 16201

F 0684 - 4/27/25 AM Med Pass, the documented reason was Drug/Item Unavailable Level of Harm - Minimal harm or potential for actual harm - 4/27/25 PM Med Pass, the documented reason was Drug/Item Unavailable - 4/28/25 AM Med Pass, the documented reason was Drug/Item Unavailable Residents Affected - Few - 4/28/25 PM Med Pass, the documented reason was Drug/Item Unavailable - 4/29/25 AM Med Pass, the documented reason was Drug/Item Unavailable: supplied by family; awaiting arrival During an interview on 4/29/25, at 9:56 a.m. the Director of Nursing (DON) stated, Resident R1 was admitted in 2023 on this cancer medication. He's his own person, but he has a brother involved. This cancer medication is $1500 a month, his brother pays out of pocket for it. There was an agreement with previous management and the brother when Resident R1 was admitted . We recently found out that this brother is now unable to order and provide the medication. He got it from a pharmacy in Delaware. He has another brother who is willing to take over and supply the medication, however since Resident R1 is his own person and responsible party, we can't give the other brother any of his medication information without his permission and Resident R1 has stated he doesn't want us to talk to his brother. During an interview on 4/29/25, at 11:19 a.m. the DON stated, We just had another meeting with Resident R1 and he is refusing to allow us to speak to his brother regarding his care. We can get his medication through our pharmacy, however he refused to give us an answer regarding how he wants the facility to proceed with obtaining his medication, he just screams at staff. During an interview on 4/29/25, at 2:43 p.m. the DON confirmed that the facility failed to provide medications as ordered by the physician for Resident R1. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1) Management. 28 Pa. Code: 211.10 (c)(d) Resident Care policies. 28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services. 395986 Page 4 of 6 395986 04/29/2025 Kittanning Health & Rehab Center 120 Kittanning Care Drive Kittanning, PA 16201

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, and interviews with staff, it was determined that the facility failed to ensure that residents are free of significant medication errors for one of five residents reviewed (Resident R1). Residents Affected - Few Findings include: Review of facility policy Medication Shortages/Unavailable Medications dated 1/12/25, indicated upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from pharmacy. If the medication is unavailable from pharmacy or a third-party pharmacy, and cannot be supplied from the manufacturer, facility should obtain alternate physician/prescriber orders, as necessary. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/19/25, indicated diagnoses of high blood pressure, depression, and personal history of malignant neoplasm of prostate (prostate cancer). Review of a physician order dated 3/11/25, indicated to administer Nubeqa (a medication given to decrease growth and spread of prostate cancer) 600 milligrams by mouth twice a day. Review of Resident R1's April 2025 Medication Administration Record revealed the scheduled medication was not administered on the following: - 4/21/25 PM Med Pass, the documented reason was Drug/Item Unavailable: medication was reordered has not arrived - 4/22/25 AM Med Pass, the documented reason was Not Administered: Refused - 4/22/25 PM Med Pass, the documented reason was Drug/Item Unavailable: family is to provide - 4/23/25 AM Med Pass, the documented reason was Drug/Item Unavailable - 4/23/25 PM Med Pass, the documented reason was Drug/Item Unavailable - 4/24/25 AM Med Pass, the documented reason was Drug/Item Unavailable - 4/24/25 PM Med Pass, the documented reason was Drug/Item Unavailable: family to supply - 4/25/25 AM Med Pass, the documented reason was Drug/Item Unavailable - 4/25/25 PM Med Pass, the documented reason was Drug/Item Unavailable - 4/26/25 AM Med Pass, the documented reason was Drug/Item Unavailable - 4/26/25 PM Med Pass, the documented reason was Drug/Item Unavailable 395986 Page 5 of 6 395986 04/29/2025 Kittanning Health & Rehab Center 120 Kittanning Care Drive Kittanning, PA 16201

F 0760 - 4/27/25 AM Med Pass, the documented reason was Drug/Item Unavailable Level of Harm - Minimal harm or potential for actual harm - 4/27/25 PM Med Pass, the documented reason was Drug/Item Unavailable - 4/28/25 AM Med Pass, the documented reason was Drug/Item Unavailable Residents Affected - Few - 4/28/25 PM Med Pass, the documented reason was Drug/Item Unavailable - 4/29/25 AM Med Pass, the documented reason was Drug/Item Unavailable: supplied by family; awaiting arrival During an interview on 4/29/25, at 9:56 a.m. the Director of Nursing (DON) stated, Resident R1 was admitted in 2023 on this cancer medication. He's his own person, but he has a brother involved. This cancer medication is $1500 a month, his brother pays out of pocket for it. We recently found out that this brother is now unable to order and provide the medication. He got it from a pharmacy in Delaware. He has another brother who is willing to take over and supply the medication, however since Resident R1 is his own person and responsible party, we can't give the other brother any of his medication information without his permission and Resident R1 has stated he doesn't want us to talk to his brother. During an interview on 4/29/25, at 11:19 a.m. the DON stated, We just had another meeting with Resident R1 and he is refusing to allow us to speak to his brother regarding his care. We can get his medication through our pharmacy, however he refused to give us an answer regarding how he wants the facility to proceed with obtaining his medication, he just screams at staff. During an interview on 4/29/25, at 2:43 p.m. the DON confirmed that the facility failed to ensure that residents are free of significant medication errors for one of five residents reviewed (Resident R1) as required. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1) Management. 28 Pa. Code: 211.10 (c)(d) Resident Care policies. 28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services. 395986 Page 6 of 6