Health inspection·December 5, 2024

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on [DATE], at 11:31 a.m. Registered Nurse (RN) Employee E1 confirmed there was no evidence of a POLST (Physician Orders for Life Sustaining Treatment- document that provides a structure for conversations about end-of-life issues and patient preferences for treatment as the end of life nears) or an advance directive in Resident R36's clinical record. During interviews on [DATE], at 11:35 a.m. RN Employee E1, Licensed Practical Nurse (LPN) Employee E4, and LPN Employee E3 confirmed that they would prioritize following the instructions on a POLST or advance directive, and that the POLST should be in the resident's clinical record. During an interview on [DATE], at 8:45 a.m. RN Employee E5 confirmed there was no evidence of a POLST or advance directive in Resident R36's clinical record, no evidence that advance directives were reviewed and a signature obtained from the resident or responsible party, and also confirmed that each clinical record should have one. Review of Resident R4's clinical record revealed an admission date of [DATE], with diagnoses that included dementia (a disease that affects short term memory and the ability to think logically), hyperlipidemia (high cholesterol), and chronic obstructive pulmonary disease (condition when your lungs do not have adequate air flow). Review of Resident R4's clinical record revealed an order for Do Not Resuscitate (DNR- medical directive that indicates that a patient does not want to receive CPR. Further review of Resident R4's clinical record revealed other than an order for a DNR, there was no evidence Resident R4 was provided written information on advance directives or assisted with the opportunity to formulate advance directives regarding treatment in the event he/she could not make decisions regarding her health care. During an interview on [DATE], at 10:46 a.m. the Director of Nursing confirmed that the facility did not have evidence of written information on advance directives for Resident R4. He/she also confirmed that Resident R4 should have written information on advance directives in his/her clinical record. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.5(f)(i) Medical records 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395363 If continuation sheet Page 2 of 15 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 12/05/2024 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)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policies and documents, and staff, resident, and visitor interviews, it was determined that the facility failed to provide housekeeping services necessary to maintain a clean environment in one resident room (520) and clean equipment for one resident (Resident R37). Findings include: A facility policy entitled Quality of Life-Homelike Environment dated 12/02/24, indicated facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting and include a clean, sanitary, and orderly environment. A facility document entitled Daily Resident/Patient Room Cleaning indicated that resident room floors would be dust mopped, all trash and debris will be swept to the door and picked up with a dustpan. Observation on 12/02/24, at 12:09 p.m. of room [ROOM NUMBER] revealed an open bag of cheese curls, two full 20-ounce plastic bottles of Diet Coke and one empty 20-ounce plastic bottle of Diet Coke on the floor on the right side of the bed between the bed frame and nightstand. Observation on 12/03/24, at 1:13 p.m. of room [ROOM NUMBER] revealed an open bag of cheese curls, one empty 20-ounce plastic bottle of Diet Coke, and an open box of tissues box on the floor on the right side of the bed between the bed frame and nightstand. Observation on 12/03/24, at 2:22 p.m. of room [ROOM NUMBER] revealed one empty 20-ounce plastic bottle of Diet Coke, and an open box of tissues box on the floor on the right side of the bed between the bed frame and nightstand, and the open bag of cheese curls on the resident's tray table. At that time, a visitor for room [ROOM NUMBER] confirmed he/she picked up the open bag of cheese curls upon entering the room. Observations on 12/03/24, at 2:22 p.m. with the Nursing Home Administrator (NHA) he/she confirmed that the food items and tissues should not have been on the floor. The NHA removed the opened bag of cheese curls from the resident room. Review of Resident R37's clinical record revealed an admission date of 2/1/24, with diagnoses that included anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), hyperlipidemia (high cholesterol) and hypertension (high blood pressure). Observations on 12/2/24, at 2:47 p.m. revealed Resident R37 sitting in his/her wheelchair on a cushion. Observations of the cushion revealed what appeared to be food stuck to the cushion. Further observations of Resident R37's wheelchair revealed what resembled food laying on the frame of the wheelchair. Observations on 12/3/24, at 10:20 a.m. revealed Resident R37's wheelchair sitting next to his/her bed. The food like substance remained on the wheelchair cushion. Further observations of Resident R37's wheelchair revealed that the food like substance remained laying on the frame of the wheelchair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395363 If continuation sheet Page 3 of 15 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 12/05/2024 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)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observations on 12/4/24, at 11:45 a.m. revealed Resident R37 sitting in his/her wheelchair with the food like substance remaining on the cushion. Further observations of Resident R37's wheelchair revealed that the food like substance remained laying on the frame of the wheelchair. During an interview on 12/4/24, at 11:48 a.m. with the NHA, he/she confirmed that there was food like substance on Resident R37's wheelchair cushion and on the frame of the wheelchair frame. He/she also confirmed that the wheelchair and cushion should be clean. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 207.2(a) Administrator's responsibility FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395363 If continuation sheet Page 4 of 15 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 12/05/2024 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)

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 Based on review of clinical records, observations, and staff interviews, it was determined that the facility failed to ensure physician's orders were followed for three of 24 residents reviewed (Residents R17, Resident R65, and Resident R69). Residents Affected - Some Findings include: Resident R69's clinical record revealed an admission date of 10/24/24, with diagnoses that included stroke, breast cancer, and high blood pressure. Resident R69's clinical record revealed a physician's order dated 10/31/24, for a left arm sling to be worn at all times except for hygiene purposes. There was also an order dated 11/20/24, for a soft cervical (neck) collar to be applied when out of bed, in wheelchair for cervical support and improved posture, may remove for eating. Observation of Resident R69 on 12/03/24, at approximately 10:47 a.m. revealed he/she was sitting in a wheelchair without a left arm sling or soft cervical collar. Observation of Resident R69 on 12/04/24, at approximately 9:20 a.m. revealed he/she was sitting in a wheelchair without a left arm sling or soft cervical collar. During an interview on 12/04/24, at 9:25 a.m. the Regional Nurse Consultant confirmed that Resident R69 was not utilizing a left arm sling or soft cervical collar as physician ordered. Resident R17's clinical record revealed an admission date of 6/07/24, with diagnoses that included hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones), and hyperlipidemia (high cholesterol). During an interview on 12/02/24, at 2:00 p.m. Resident R17 revealed that he/she was to have a dermatology appointment for his/her skin rash. He/she stated that the appointment was canceled due to COVID and he/she has yet to have an appointment with dermatology. Resident R17's clinical record revealed a physician's order dated 9/05/24, to schedule Telederm (a dermatology evaluation done remotely) appointment. Resident R17's clinical record lacked evidence that the appointment was scheduled or that Resident R17 has had a dermatology appointment. During an interview on 12/04/24, at 11:52 a.m. the Director of Nursing (DON) confirmed that the Telederm appointment was never scheduled. He/she also confirmed that the appointment should have been scheduled per physician orders. Resident R65's clinical record revealed an admission date of 12/27/23, with diagnoses that included hemiplegia (a condition where a person is paralyzed and unable to move one side of their body), and hypertension (high blood pressure). Resident R65's physician orders revealed, an order dated 5/20/24, for contracture boot application to right foot/ankle to be worn at all times except for general hygiene and regular skin checks. Resident R65's care plan revealed a care plan focus of ADL (Activities of Daily Living) Self Care: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395363 If continuation sheet Page 5 of 15 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 12/05/2024 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)

F 0684 with an intervention of use assistive/adaptive equipment: contracture boot to right ankle/foot dated 5/20/24. Level of Harm - Minimal harm or potential for actual harm Observation made on 12/02/24, at 3:10 p.m. revealed Resident R65 sitting in his/her wheelchair without a boot to his/her right foot/ankle. Observation on 12/02/24, at 3:22 p.m. revealed Resident R65 sitting in his/her wheelchair without a boot on his/her right foot/ankle. Observation on 12/02/24, at 4:00 p.m. revealed Resident R65 sitting in his/her wheelchair without a boot to his/her right foot/ankle. Observation on 12/03/24, at 11:00 a.m. revealed Resident R65 lying in his/her bed without a boot to his/her right foot/ankle. Observation on 12/04/24, at 10:32 a.m. revealed Resident R65 lying in his/her bed without a boot to his/her right foot/ankle. Residents Affected - Some During observations and interview on 12/04/24, at 11:59 a.m. with the DON, he/she confirmed that Resident R65 did not have a boot on his/her right foot/ankle. He/she also confirmed that Resident R65 should have a boot on his/her right ankle as ordered by the physician. 28 Pa. Code 211.5(f)(i) Clinical records 28 Pa. Code 211.12 (d)(1)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395363 If continuation sheet Page 6 of 15 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 12/05/2024 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)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and clinical records, observations, and staff interviews, it was determined that the facility failed to ensure that a resident with limited range of motion received treatment and services to prevent further decrease in range of motion for one of two residents reviewed for range of motion (Resident R65). Findings include: Review of Resident R65's clinical record revealed an admission date of 12/27/23, with diagnoses that included hemiplegia (a condition where a person is paralyzed and unable to move one side of their body), Gastro Esophageal Reflux Disease (a condition when stomach acid repeatedly flows back up into your throat), and Hypertension (high blood pressure). Review of Resident R65's Occupational Therapy Discharge summary dated [DATE], revealed a long term goal that include: patient will safely wear a resting hand splint on left hand for up to eight hours with minimal signs or symptoms of redness, swelling, discomfort or pain. Observation made on 12/02/24, at 3:10 p.m. revealed Resident R65 sitting in his/her wheelchair with hand splint lying on bedside stand and no hand splint to his/her left hand. Observation on 12/02/24, at 3:22 p.m. revealed Resident R65 sitting in his/her wheelchair with hand splint lying on bedside stand and no hand splint to his/her left hand. Observation on 12/02/24, at 4:00 p.m. revealed Resident R65 sitting in his/her wheelchair with hand splint lying on bedside stand and no hand splint to his/her left hand. Observation on 12/03/24, at 11:00 a.m. revealed Resident R65 lying in his/her bed with hand splint lying on bedside stand and no hand splint to his/her left hand. Observation on 12/04/24, at 10:32 a.m. revealed Resident R65 lying in his/her bed with no resting hand splint to his/her left hand. During all above observations there was a sign on the wall in Resident R65's room at the head of bed that read Resting hand splint on at all times during day (wake up to HS) (hour of sleep). During an interview on 12/03/24, at 11:00 a.m. with the Resident R65 and his/her significant other revealed that Resident R65 should have a hand splint applied to his/her left hand during the day. Resident R65 stated that he/she cannot remember the last time his/her hand splint was applied to his/her left hand. Resident R65's significant other stated that the hand splint was laying on Resident R65's nightstand in his/her room and that there was a sign above the head of Resident R65's bed that reminded staff to apply the hand splint. Significant other stated that Resident R65 has had three different room changes and the sign above Resident R65's bed has been placed above Resident R65's bed in all three rooms. Resident R65 and significant other further expressed that Resident R65's fingers push into his/her hand which causes his/her fingernails to push into his/her skin. Resident R65 stated that he/she wants the resting hand splint to be applied. Resident R65 stated that staff never applies the hand splint. During an interview with the Director of Rehab (DOR) on 12/05/24, at 8:57 a.m. he/she revealed that when Resident R65 discharged from therapy services he/she was discharged with a resting hand splint to be applied to Resident R65's left hand for eight hours a day. DOR expressed that the process to continue resident goals after a resident is discharged from therapy is that the resident's long term (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395363 If continuation sheet Page 7 of 15 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 12/05/2024 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)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some goals are e-mailed to the Director of Nursing (DON) and the DON inputs the goals into the plan of care for the nursing staff. During observations and interview on 12/04/24, at 11:59 a.m. with the DON, he/she confirmed that Resident R65 did not have a hand splint to his/her left hand and a sign was posted at the head of Resident R65's bed for the hand splint to be applied. The DON also confirmed that the hand splint should be applied every day. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395363 If continuation sheet Page 8 of 15 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 12/05/2024 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)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on review of facility policies and clinical records, observations, and staff interviews, it was determined that the facility failed to provide appropriate care regarding a urinary catheter (a tube inserted into the bladder to drain urine into a bag) for three of five residents reviewed for catheters (Residents R1, R5, and R11) Findings include: A facility policy entitled Suprapubic Catheter Replacement dated 12/02/24, indicated that the date and time of the procedure, name of individual performing the procedure, and signature and title of the person completing the procedure should be recorded in the resident's medical record. A facility policy entitled Catheter Care, Urinary dated 12/02/24, indicated Maintain Unobstructed Urine Flow 3. The urinary drainage bag must be held or positioned lower than the bladder at all times . and Infection Control 2. b. Be sure the catheter tubing and drainage bag are kept off the floor. Resident R1's clinical record revealed an admission date of 12/22/22, with diagnoses that included obstructive and reflux uropathy (occurs when the urine flow is blocked due to an obstruction and the urine flows backwards from the bladder into the kidneys), diabetes (a health condition caused by the body's inability to produce enough insulin), and high blood pressure. Resident R1's clinical record revealed a physician's order dated 3/16/24, and again on 7/12/24, that indicated Suprapubic Catheter change monthly every day shift every 30 days and Suprapubic Catheter bag change monthly every day shift every 30 days. Review of the Treatment Administration Record (TAR) and clinical record progress notes lacked evidence that Resident R1's Suprapubic Catheter and Suprapubic Catheter Bag was changed during the month of April 2024 , June 2024, and November 2024 as ordered by the physician. During an interview on 12/04/24, at 1:36 p.m. the Regional Nurse Consultant confirmed that the facility lacked evidence that Resident R1's Suprapubic Catheter and Bag were changed in April, June, and November 2024 per physician orders. Resident R5's clinical record revealed an admission date of 10/19/07, with diagnoses that included obstructive and reflux uropathy, and dementia (a disease that affects short term memory and the ability to think logically). Resident R5's physician orders revealed an order dated 11/30/24, for a foley catheter. Observation on 12/02/24, at 3:08 p.m. revealed Resident R5's urinary drainage bag lying on the floor without a cover in place and the drainage valve (the part of the urinary bag that opens to empty urine from the bag) touching the floor. Observation on 12/02/24, at 3:45 p.m. revealed Resident R5's urinary drainage bag remained lying on the floor without a cover in place and the drainage valve touching the floor. Observation on 12/02/24, at 4:13 p.m. with the Registered Nurse Assessment Coordinator (RNAC) revealed Resident R5's urinary drainage bag remained lying on the floor without a cover in place and the drainage valve touching the floor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395363 If continuation sheet Page 9 of 15 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 12/05/2024 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)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 12/02/24, at 4:13 p.m. the RNAC confirmed that the urinary drainage bag was lying on the floor with the drainage valve touching the floor and without a cover on the urinary drainage bag. He/she also confirmed that the urinary drainage bag should not be on the floor and the urinary drainage bag should have a cover on it. Resident R11's clinical record revealed an admission date of 10/30/23, with diagnoses that included neurogenic bladder dysfunction (urinary bladder problem due to disease or injury of the nervous system involved in the control of urine), and hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones). Resident R11's physician orders revealed an order dated 10/16/24, for foley catheter. Observation on 12/02/24, at 3:11 p.m. revealed Resident R11 was sitting in his/her wheelchair with his/her foley catheter drainage bag hanging off of his/her wheelchair armrest and was higher than their bladder. Observation made on 12/02/24, at 3:47 p.m. revealed Resident R11 remained sitting in his/her wheelchair with his/her foley catheter hanging off of his/her wheelchair armrest and was higher than their bladder. Observation on 12/02/24, at 4:16 p.m. with the RNAC revealed Resident R11 was sitting in his/her wheelchair with his/her foley catheter drainage bag hanging off of his/her wheelchair armrest and was higher than their bladder. During an interview on 12/02/24, at 4:16 p.m. the RNAC confirmed that Resident R11's foley catheter was hanging off of his/her wheelchair arm rest above Resident R11's bladder. He/she also confirmed that Resident R11's foley catheter should not be placed above his/her bladder. 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395363 If continuation sheet Page 10 of 15 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 12/05/2024 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)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to obtain a physician's order for the provision of oxygen therapy for one of one residents reviewed for respiratory services (Resident R26). Residents Affected - Few Findings include: A facility policy entitled Oxygen Administration dated 12/02/24, indicated to verify that there is a physician's order for oxygen administration. Resident R26's clinical record revealed an admission date of 11/06/24, with diagnoses that included chronic obstructive pulmonary disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), dementia (loss of cognitive functioning affecting a persons memory and behaviors), and high blood pressure. Observations on 12/02/24, at 1:45 p.m., 12/03/24, at 11:16 a.m., and 12/03/24, at 12:08 p.m. revealed Resident R26 wearing an oxygen nasal cannula (a thin tube with two prongs that fits into the resident's nostrils to deliver oxygen) connected to an oxygen concentrator delivering 2 liters per minute. Resident R26's clinical records under Oxygen sats summary revealed he/she utilized oxygen on 11/15/24, 11/16/24, 11/29/24, 12/01/24, 12/02/24, and 12/03/24. Clinical record progress notes revealed he/she utilized oxygen on 11/15/24, 11/16/24, 11/17/24, 11/25/24, 11/26/24, 11/27/24, 11/28/24, 11/29/24, 11/30/24, 12/01/24, 12/02/24, and 12/03/24. Resident R26's clinical record lacked evidence of a physician's order for the use of oxygen therapy. During an interview on 12/03/24, at 12:25 p.m. Licensed Practical Nurse Employee E4 confirmed that Resident R26 was being administered oxygen therapy and their clinical record lacked a physician's order for oxygen therapy. 28 Pa. Code 211.5(f)(i) Medical records 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395363 If continuation sheet Page 11 of 15 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 12/05/2024 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to label multi-dose containers of insulin (medication to treat elevated blood sugar levels) with the date they were opened and discard an opened multi-dose vial of insulin in a timely manner in two of three medication carts (Gold and Red Units) and discard an opened multi-dose vial of Tuberculin solution (solution used to test for the disease tuberculosis) in one of three medication storage rooms (Red Unit). Findings include: A facility policy entitled, Insulin Administration dated [DATE], indicated that staff are to check the expiration date, if drawing from an opened multi-dose vial; if opening a new vial, record expiration date and time on the vial (follow manufacturer recommendations for expiration after opening. A facility policy entitled, Storage of Medications dated [DATE], indicated when the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated; the nurse shall place a date opened sticker on the medication and enter the date opened and new date of expiration; the expiration date of the vial or container will be 30 days unless the manufacturer recommends another date or regulations/guidelines require different dating. Observation on [DATE], at 8:57 a.m. of Gold Unit medication cart revealed opened multidose insulin pens for Residents R125, R8, and a multidose vial of insulin for R46 lacking an opened/use-by date, and an opened multidose vial of insulin for Resident R62 dated as opened on [DATE], (expired five days). During an interview at that time, Licensed Practical Nurse (LPN) Employee E3 and Registered Nurse Employee E1 confirmed that the opened undated multidose insulin pens and vial should be labeled with the opened date to determine the discard date, and that the opened multidose vial of insulin dated [DATE], was expired and should have been discarded. Observation on [DATE], at 9:05 a.m. of Red Unit medication cart revealed one opened multidose insulin pen for Resident R27, two opened multidose insulin pens for Resident R10 and R227 lacking an opened/use-by date. Observation on [DATE], at 9:11 a.m. of Red Unit medication room revealed one opened multidose vial of Tuberculin solution dated opened [DATE], and labeled to discard in 28 days (seven days expired). During an interview at that time, LPN Employee E2 confirmed that the opened undated multidose insulin pens should be labeled with the opened date to determine the discard date, and that the opened multidose vial of Tuberculin solution was expired and should have been discarded. 28. Pa. Code 201.18(b)(1) Management 28. Pa. Code 211.9(a)(1) Pharmacy services (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395363 If continuation sheet Page 12 of 15 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 12/05/2024 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)

F 0761 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.10(c) Resident care policies Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395363 If continuation sheet Page 13 of 15 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 12/05/2024 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on review of facility policies, observations, and staff interview, it was determined that the facility failed to maintain sanitary operations and standards for food safety in the main kitchen and in one pantry reviewed (Gold Pantry). Findings include: Review of facility policy entitled Food Receiving and Storage dated 12/02/24, indicated that Dry food that are stored in bins are removed from original packaging, labeled and dated (use by date). Food and snacks kept on the nursing units. 1. All food items to be kept at or below 41 F [Fahrenheit] are placed in the refrigerator . and labeled with a use by date. 3. Refrigerators . are monitored for temperature according to state specific guidelines. Additional document entitled Food Storage Guide revealed that bakery items including, muffins/pastries/donuts-once opened expires in one week and prepared foods/leftover items, once opened expires in 3 days. Review of facility policy entitled Food Brought by Family/Visitors dated 12/02/24, revealed that 'food brought in by family/visitors that is left with resident to consume later will be labeled .perishable foods must be stored in re-sealable containers . containers will be labeled with resident's name, the item and the use by date .the facility staff will discard perishable foods on or before the use by date. Review of Monthly Sanitation Audit document revealed that vents were to be inspected to be secure, clean and free from dust and drains were to be inspected to be clean and working properly. Observation of the main kitchen on 12/02/24, at 11:35 a.m. with the Dietary Manager revealed a metal container with cake-like squares in individual baggies and the baggies lacked a label and date. Observations of two heating units attached to the kitchen ceiling at each end of the food preparation areas revealed the vents on each of the heating units had a thick layer of a gray fuzzy substance. Observation in the dishwashing area revealed a food disposal attached under the sink with a thick layer of a dry brown substance. During an interview with the Dietary Manager on 12/02/24, at 11:45 a.m. he/she confirmed the cake-like item's were not labeled or dated, he/she confirmed that the heater vents over the food preparation area had a thick layer of a gray fuzzy substance, and the food disposal under the sink had a thick layer of a dry brown substance. He/she also confirmed that the cake-like substance should be dated and labeled, and the heater vents and the food disposal should be clean. Observations on 12/02/24, at 11:46 a.m. revealed a refrigerator in the pantry used for residents contained food on a paper plate covered with foil with no date; a paper plate in a ziplock bag with a piece of pie with no name or date; an open bottle of Pepsi with no name or date. Observations of a freezer in the pantry used for residents revealed an open half gallon container of ice cream with no name or date and ice packs that are used as treatments for residents. Observation of temperature logs posted on the front of the refrigerator and freezer revealed a log for the month of November 2024, with the log for the refrigerator lacking temperatures for the last five days, and the freezer log was lacking temperature for the last three days. Additionally, there was no evidence of temperatures (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395363 If continuation sheet Page 14 of 15 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 12/05/2024 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)

F 0812 logged for the month of December 2024. Level of Harm - Minimal harm or potential for actual harm During an interview on 12/02/24, at 11:50 a.m. the Assistant Director of Nursing confirmed that the food items in the pantry refrigerator and freezer lacked names and/or dates. He/she confirmed that the ice packs used as treatments for residents were in the freezer with food and he/she confirmed that the temperature logs on the refrigerator and freezer lacked temperatures. He/she confirmed that food items should be labeled and dated, ice packs used as treatments should not be stored in the same unit with food, and temperatures of the refrigerator and freezer should be logged daily. Residents Affected - Some 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395363 If continuation sheet Page 15 of 15