Health inspection·January 9, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on review of clinical records, facility policies and documentation, and staff interview, it was determined that the facility failed to ensure adequate safety measures were implemented related to wheelchair transport and fall precautions for two of four residents reviewed for falls (Residents R13 and R14). Findings include: The facility was not able to provide a policy for staff to reference in the safe utilization of footrests while transporting residents via wheelchair. A facility policy entitled, Falls and Fall Risk, Managing, revised March 2018, indicated that Position-change alarms will not be used as the primary or sole intervention to prevent falls, but rather will be used to assist the staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner. Resident R13's clinical record revealed an admission date of 11/28/24, with diagnoses that included stroke, unsteady on feet, Parkinson's Disease (degenerative brain condition, meaning it causes parts of your brain to deteriorate, that causes slowed movements, tremors, balance problems and more), dysarthria and anarthria (motor speech disorder that makes it difficult to control the muscles used for speaking). Resident R13's Minimum Data Set (MDS- standardized assessment tool used to evaluate the health of nursing home residents) with an assessment reference date of 11/29/24, Section GG - Functional Abilities, GG0170S was coded as requiring partial/moderate assistance to propel his/her manual wheelchair 150 feet in a corridor or similar space. Resident R13's clinical record also revealed a departmental progress note dated 12/08/24, that indicated Resident R13 was being pushed in a wheelchair, lost his/her balance and hit right lower area of face and that the physician was notified and Resident R13 was transported to the acute hospital for evaluation and admitted . The facility investigation revealed an Interdisciplinary Team review of Resident R13's fall indicated the resident was being pushed in a wheelchair on ramp by staff and put his/her feet down and fell. During an interview on 1/07/25, at 8:39 a.m. the Nursing Home Administrator confirmed Resident R13 should have had footrests attached to his/her wheelchair while being pushed by staff. (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 2 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 01/09/2025 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)