Kinzua Nursing and Rehab
205 Water Street, Warren, PA 16365 · Warren County · 106 certified beds · avg 81 residents/day · certified since Apr 30, 1977
Part of chain: VALLEY WEST HEALTH (12 facilities, chain avg rating 3.3★)
2/5
Health inspection rating (on-site)
1
Serious findings on record
$145,181
Fines, last 3 years
3.69
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Feb 26, 2026 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Mar 11, 2026 (Deficient, Provider has date of correction)
All citations in the current public record (34)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 6, 2026 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Feb 26, 2026 | ▲ J · Immediate jeopardy, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Feb 26, 2026 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Feb 26, 2026 | D · Potential for harm, one-off | The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. · from a complaint |
| Dec 11, 2025 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Dec 11, 2025 | D · Potential for harm, one-off | The facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way. |
| Dec 11, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Sep 5, 2025 | E · Potential for harm, repeated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Jul 25, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Jul 25, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Jul 25, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Mar 24, 2025 | F · Potential for harm, facility-wide | The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. · from a complaint |
| Mar 24, 2025 | E · Potential for harm, repeated | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint |
| Mar 24, 2025 | D · Potential for harm, one-off | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. · from a complaint |
| Mar 24, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Mar 24, 2025 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| Jan 9, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Dec 5, 2024 | E · Potential for harm, repeated | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Dec 5, 2024 | E · Potential for harm, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Dec 5, 2024 | E · Potential for harm, repeated | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Dec 5, 2024 | E · Potential for harm, repeated | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Dec 5, 2024 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Dec 5, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Dec 5, 2024 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Dec 5, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Aug 22, 2024 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Mar 6, 2024 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Jan 26, 2024 | E · Potential for harm, repeated | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. |
| Jan 26, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jan 26, 2024 | D · Potential for harm, one-off | The facility did not let a resident help develop and carry out their own plan of care — the written roadmap of the services and support they'll receive, built around their personal goals and preferences. |
| Jan 26, 2024 | D · Potential for harm, one-off | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
| Jan 26, 2024 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Jan 26, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Jan 4, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (8 → 3).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2024 | 17 | 0 | E |
| 2025 | 13 | 0 | F |
| 2026 | 4 | 1 | J ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $145,181.
| Date | Type | Amount / length |
|---|---|---|
| Feb 26, 2026 | Fine | $145,181 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Pennsylvania avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.69 | 3.94 | 3.95 | top 49% in Pennsylvania; bottom 46% in the U.S. |
| Registered Nurse hours | 0.51 | 0.80 | 0.69 | bottom 27% in Pennsylvania; bottom 39% in the U.S. |
| Weekend total nurse staffing | 3.55 | 3.58 | 3.50 | top 40% in Pennsylvania; top 40% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.34 | 0.56 | 0.48 | bottom 32% in Pennsylvania; bottom 41% in the U.S. |
| Total nursing staff turnover (%) | 48.9 | 44.5 | 45.8 | bottom 37% in Pennsylvania; bottom 40% in the U.S. |
| RN turnover (%) | 83.3 | 39.9 | 42.9 | bottom 1% in Pennsylvania; bottom 4% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.72, RN 0.51, weekend 3.59. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 2/5 · long-stay residents: 1/5 · short-stay residents: 3/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Western Pa Opco Holdings I LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 10/29/2024 |
| Andrews, Heather | Individual | ADP of the SNF | NOT APPLICABLE | 12/20/2024 |
| Beverly Enterprises - Pennsylvania, INC. | Organization | ADP of the SNF | NOT APPLICABLE | 12/20/2024 |
| Beverly Enterprises LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/20/2024 |
| Beverly Health and Rehabilitiation Services, INC | Organization | ADP of the SNF | NOT APPLICABLE | 12/20/2024 |
| Chase, Andrew | Individual | ADP of the SNF | NOT APPLICABLE | 12/20/2024 |
| Drumm Intermediary Sub Co LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/20/2024 |
| Drumm Merger Co | Organization | ADP of the SNF | NOT APPLICABLE | 12/20/2024 |
| Drumm Merger Co Sub LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/20/2024 |
| Endres, Jay | Individual | ADP of the SNF | NOT APPLICABLE | 12/20/2024 |
| Fillmore Strategic Investors LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/20/2024 |
| Finn, Nicholas | Individual | ADP of the SNF | NOT APPLICABLE | 12/20/2024 |
| Franco, Aharon | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/29/2024 |
| Franco, Aharon | Individual | ADP of the SNF | NOT APPLICABLE | 10/29/2024 |
| Geary Property Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/20/2024 |
| GPH Warren Kinzua Valley LP | Organization | ADP of the SNF | NOT APPLICABLE | 12/20/2024 |
| Iskeb Western Pa LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/20/2024 |
| Keystone Ventures LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/20/2024 |
| Linam, Kim | Individual | ADP of the SNF | NOT APPLICABLE | 12/20/2024 |
| Lucks, Karen | Individual | ADP of the SNF | NOT APPLICABLE | 12/20/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "What were the findings behind this administration citation, and what has leadership changed since?"
- "How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
- "If my family member's health suddenly changes, how quickly do you reassess them and update their care?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "How do you keep residents' medical records accurate, complete, and secure?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Warren Manor | 2.0 mi | Warren, PA | ★★★☆☆ | 3/5 | |
| Rouse Warren County Home | 8.0 mi | Youngsville, PA | ★☆☆☆☆ | 2/5 | abuse |
| Heritage Park Rehab & Skilled Nursing | 17.6 mi | Jamestown, NY | ★☆☆☆☆ | 1/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 395363.