Health inspection·January 26, 2024

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Allow resident to participate in the development and implementation of his or her person-centered plan of care. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and clinical records, and staff and resident interviews, it was determined that the facility failed to ensure that the resident was offered the opportunity to participate in the development, review, and/or revision of their person-centered care plan for two of 24 residents reviewed (Residents R29 and R73). Findings include: Review of facility policy dated 1/16/24, entitled, Resident Participation - Assessment/Care Plan indicated: - the resident and his or her representative have the right to participate in the development and implementation of his or her care plan. - the resident and his/her legal representative are encouraged to attend and participate in development of the resident's person-centered care plan. - the care planning process will facilitate the inclusion of the resident and/or representative. - a seven (7) day advance notice of the care planning conference is provided to the resident and/or representative - the Social Services Director or designee is responsible for notifying the resident and/or representative and for maintaining records of such notices (date, time, and location of conference; name of person contacted and date of contact; method of contact; input from resident/representative if not able to attend; refusal of participation; and date and signature of individual making contact). Resident R29's clinical record revealed an admission date of 6/10/15, with diagnoses that included diabetes (a condition where the body produces insufficient amounts of insulin, causing high blood sugar), atrial fibrillation (an abnormal, rapid heartbeat that is present all the time, causing shortness of breath, heart palpitations, and weakness and can lead to development of blood clots), and abnormalities of gait and mobility (difficulty walking). Review of Resident R29's Significant Change Minimum Data Set (MDS- a federally mandated standardized assessment conducted at specific intervals to plan resident care needs), with an Assessment Reference Date (ARD-a look back period of time for the MDS assessment) of 1/9/24, revealed that Resident R29 has mild cognitive impairment. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 9 Event ID: 395363 Printed: 05/15/2026 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 395363 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kinzua Nursing and Rehab 205 Water Street Warren, PA 16365 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)