Health inspection·March 24, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of 15 Residents reviewed (Resident R1). Residents Affected - Few Findings include: Review of facility policy dated 12/2/24, entitled Comprehensive Assessment and The Care Delivery Process indicated that a comprehensive assessment will be conducted to assist in developing person-centered care plans. It also indicated to identify current interventions and treatments and link these to problems and diagnosis they are to be treating. Resident R1's clinical record revealed an admission date of 1/8/25, with diagnoses that included high blood pressure, pneumonia, and pressure ulcer (damage to the skin and/or underlying tissue that usually occurs over a bony prominence) to his/her right heel and sacrum that is unstageable (when the bottom of the pressure ulcer is covered in slough [debris that appears tan, yellow, green or brown in color] and/or eschar [hard plaque that's tan, brown, or black in color]. Resident R1's clinical record revealed a progress noted dated 2/19/25, identifying pressure ulcers to his/her right heel and sacrum were discovered with physician orders dated for 2/19/25, to implement treatments to his/her right heel and sacrum. Progress notes also indicated that Resident R1 started seeing wound care consultant company on 2/28/25, for weekly wound assessments, measurements, and changes in treatments if applicable. Resident R1's clinical record lacked evidence that a care plan had been developed to address his/her actual skin integrity impairment and the presence of pressure ulcers to his/her right heel and sacrum. During an interview on 3/17/25, at 10:05 a.m. the Director of Nursing confirmed that a care plan had not been developed to address Resident R1's pressure ulcers to his/her right heel and sacrum. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395363 If continuation sheet Page 2 of 11 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 03/24/2025 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)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to review and/or revise resident care plans for seven of 15 residents reviewed (Residents R9, R10, R8, R15, R16, R20, and R22). Findings include: Review of facility policy dated 12/2/24, entitled Comprehensive Assessment and The Care Delivery Process indicated that comprehensive assessments, care planning, and the care delivery process involves collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions. Resident R9's clinical record revealed an admission date of 2/2/08, with diagnoses that included diabetes (a health condition caused by the body's inability to produce enough insulin), high blood pressure, and anxiety. Review of Resident R9's comprehensive care plan on 3/17/25, revealed that of the 39 care plans present, 37 had an outstanding target date of 2/28/25. The care plans included the problem categories of: skin breakdown related to rash, ADL [activities of daily living] care, anticoagulant therapy, aspirin therapy, adverse effected related to medications, elimination related to bowel and bladder, hydration, risk for skin integrity, risk for skin integrity related to diabetes and venous insufficiency, behaviors, coronavirus, falls, communication, pain, cardiac disease, mental status, dental, endocrine system, enhance barrier precautions, enhanced barrier precautions related to wounds, activities, paranoia, eye drops, GI distress, gastrointestinal, inappropriate behaviors, infection, hematology, adjustment, nutrition, discharge, leave of absence, advanced directive, steroid use, surgical wounds, pressure ulcers, and urinary incontinence. Review of Resident R9's comprehensive care plan on 3/17/25, revealed that of the 39 care plans present, two had no goals. The care plans included problem categories of: actual skin breakdown and safety. Resident R10's clinical record revealed an admission date of 2/7/25, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), diabetes, and high blood pressure. Review of Resident R10's comprehensive care plan on 3/17/25, revealed that of the 15 care plans present, 15 had an outstanding target date of 2/27/25. The care plans included the problem categories of: anticoagulant therapy, skin integrity, falls cardiac disease, discharge planning, diuretic use, vision, urinary incontinence, activities, nutrition, hearing, adjustment, communication, pain, and activities. During an interview on 3/17/25, at 10:50 a.m. the Director of Nursing confirmed that Residents R9 and R10's care plans were not reviewed and/or revised within the required timeframe and Resident R9's care plans lacked goals for all problem areas. Resident R8's clinical record revealed an admission date of 3/19/22, with diagnoses that included anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395363 If continuation sheet Page 3 of 11 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 03/24/2025 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)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few someone), high blood pressure, and osteoporosis (a condition where bone strength weakens and is susceptible to breaking). Review of Resident R8's comprehensive care plan on 3/19/25, revealed that of the 30 care plans present, 30 had an outstanding target date of 2/19/25. The care plans included the problem categories of: pain, ADL's, coronavirus, falls, adverse effects, cardiac disease, urinary incontinence, bowel elimination, musculoskeletal, skin, nutrition, elopement, toileting, vision, gastrointestinal, hematological, cognitive, endocrine, activities, coping, dental, communication, mood, sleep, discharge potential, hydration, discharge planning, advanced directives, aspirin use, and respiratory. Resident R15's clinical record revealed an admission date of 1/24/25, with diagnoses that included osteomyelitis of the vertebra (infection of the bone), high blood pressure, and anxiety. Review of Resident R15's comprehensive care plan on 3/19/25, revealed that of the 21 care plans present, 21 had an outstanding target date of 2/13/25. The care plans included the problem categories of: vision, infection of the skin, enhanced barrier precautions, skin integrity, skin breakdown, pain, indwelling catheter, falls, discharge plan, IV, activities, nutrition, aspirin use, ADL's, diuretic therapy, gastrointestinal distress, surgical wounds, side effects, cardiac disease, hydration/constipation, and risk for PI (pressure injury). Resident R16's clinical record revealed an admission date of 10/29/22, with diagnoses that included metabolic encephalopathy (a condition where the brain function is disturbed temporarily or permanently due to various disease or toxins in the body), pneumonia, and high blood pressure. Review of Resident R16's comprehensive care plan on 3/19/25, revealed that of the 33 care plans present, 29 had an outstanding target date of 2/5/25. The care plans included the problem categories of: skin integrity, endocrine, hematological, cardiac, urinary incontinence, pain, gastrointestinal distress, ADL's, nutrition, falls, potential for cavities, side effects from psychotropic's, elopement, cognitive loss, activities, bowels, anticoagulant, depression, communication, neurological, advances directives, falls, COVID, aspirin use, urinary tract infections, hydration, adverse effects from medications, skin integrity, and toileting. Review of Resident R16's comprehensive care plan on 3/19/25, revealed that of the 33 care plans present, four had no goals or interventions. The care plans included problem categories of: discharge potential, enhanced barrier precautions, infection - urinary tract, and safety related to hot liquids. Resident R20's clinical record revealed an admission date of 1/24/25, with diagnoses that included metabolic encephalopathy, respiratory failure (a condition where you don't get enough oxygen or you get too much carbon dioxide in your body), and high blood pressure. Review of Resident R20's comprehensive care plan on 3/19/25, revealed that of the 20 care plans present, 20 had an outstanding target date of 2/12/25. The care plans included the problem categories of: hearing, vision, anticoagulant, respiratory, diuretic use, cellulitis, risk for skin impairment, actual skin impairment, ADL's, discharge plan, cardiac, endocrine, steroid therapy, nutrition, advanced directive, side effects, hydration, falls, dental, and activities. Resident R22's clinical record revealed an admission date of 2/24/25, with diagnoses that included deep vein thrombosis (DVT - when a blood blot forms in a deep vein), urinary tract infection, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395363 If continuation sheet Page 4 of 11 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 03/24/2025 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)

F 0657 dementia (loss of cognitive functioning affecting a persons memory and behaviors). Level of Harm - Minimal harm or potential for actual harm Review of Resident R22's comprehensive care plan on 3/19/25, revealed that of the 15 care plans present, 15 had an outstanding target date of 3/13/25. The care plans included the problem categories of: safety, cardiac, side effects, toileting, falls, communication, enhanced barrier precautions, falls, cognitive loss, nutrition, vision, urinary incontinence, hydration, ADL's, and dental. Residents Affected - Few Review of Resident R22's comprehensive care plan on 3/19/25, revealed that of the 15 care plans present, one had no interventions. The care plan included problem category of: enhanced barrier precautions. During an interview on 3/19/25, at 11:50 a.m. p.m. the Registered Nurse Assessment Coordinator confirmed that Residents R8, R15, R16, R20, and R22's care plans were not reviewed and/or revised within the required timeframes, Resident R16's care plans lacked goals and interventions for all problem areas, and Resident R22's care plan lacked interventions for all problem areas. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395363 If continuation sheet Page 5 of 11 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 03/24/2025 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)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, job description, and clinical records, and staff interviews, it was determined that the facility failed to accurately and consistently assess a resident's nutritional status on admission and as needed thereafter and failed to complete a comprehensive nutritional assessment on a resident identified as being at risk for unplanned weight loss and/or compromised nutritional status for 27 of 85 Residents reviewed (Residents R1, R10, R11, R15, R20, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, R37, R38, R39, R40, R41, R42, and R43) Residents Affected - Some Findings include: Review of facility policy dated 12/2/24, entitled Nutritional Management revealed the facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status (refers to the factors that reflect that an individual's nutritional status (includes both nutrition and hydration) is adequate, relative to his/her overall condition and prognosis, such as weight, food/fluid intake, and pertinent laboratory values) in the context of his or her overall condition. The policy further stated that a comprehensive nutritional assessment will be completed by a dietitian within seven-two hours of admission, annually, and upon significant change in condition and that follow-up assessments will be completed as needed. The assessments may include, but are not limited to general appearance; height and weight; cognitive, physical, and medical conditions; food and fluid intake; evidence of fluid loos or retention; presence of persistent hunger, poor intake, or continued weight loss; review of medication list; and review of laboratory / diagnostic data. The dietitian shall use data gathered from the nutritional assessment to estimate the resident's calorie, nutrient, and fluid needs and whether intake is adequate to meet those needs. Facility provided job description entitled Registered Dietitian Consultant revealed that he/she is responsible to ensure residents' clinical needs are provided by the food and nutrition service department. He/she will also review the dietary requirements of each resident admitted to the facility and assist the attending physician in planning for the resident's prescribed diet plan as well as assessing nutritional needs of each resident. Resident R1's clinical record revealed an admission date of 1/8/25, with diagnoses that included high blood pressure, pneumonia, and pressure ulcer (damage to the skin and/or underlying tissue that usually occurs over a bony prominence) to his/her right heel and sacrum that is unstageable (when the bottom of the pressure ulcer is covered in slough [debris that appears tan, yellow, green or brown in color] and/or eschar [hard plaque that's tan, brown, or black in color]. Resident R1's clinical record revealed the following weights: 1/09/25 - 149; 2/02/25 - 136.0; and 3/16/25 123.4. A significant weight loss of 9.26% in 17.18 % in two months. Resident R1's clinical record revealed a progress note dated 2/19/25, that indicated he/she had a new pressure ulcer located on the right heel and sacrum. Resident R1's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission, with development of a right heel and sacrum pressure ulcer, with continuous weight loss and/or throughout his/her stay at the facility at this time. Resident R10's clinical record revealed an admission date of 2/7/25, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395363 If continuation sheet Page 6 of 11 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 03/24/2025 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)

F 0692 Level of Harm - Minimal harm or potential for actual harm resulting in difficulty breathing), diabetes (a health condition caused by the body's inability to produce enough insulin), and high blood pressure. Resident R10's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Residents Affected - Some Resident R11's clinical record revealed an admission date of 1/31/25, with diagnoses that included dementia (loss of cognitive functioning affecting a persons memory and behaviors), flu, and gastro-esophageal reflux disease (a condition where stomach acid flows back into the esophagus [tube that passes food from the mouth into the stomach]). Resident R11's clinical record revealed he/she was discharged to the hospital on 2/14/25, with return anticipated. Further review of Resident R11's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility. Resident R15's clinical record revealed an admission date of 1/24/25, with diagnoses that included osteomyelitis of the vertebra (infection of the bone), high blood pressure, and anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone). Resident R15's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Resident R20's clinical record revealed an admission date of 1/24/25, with diagnoses that included metabolic encephalopathy (a condition where the brain function is disturbed temporarily or permanently due to various disease or toxins in the body), respiratory failure (a condition where you don't get enough oxygen or you get too much carbon dioxide in your body), and high blood pressure. Resident R20's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Resident R22's clinical record revealed an admission date of 2/24/25, with diagnoses that included deep vein thrombosis (DVT - when a blood blot forms in a deep vein), urinary tract infection, and dementia. Resident R22's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Resident R23's clinical record revealed an admission date of 3/12/25, with diagnoses that included pneumonia, COPD, and diabetes. Resident R23's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Resident R24's clinical record revealed an admission date of 2/5/25, with diagnoses that included dementia, high blood pressure, and anxiety. Resident R24's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395363 If continuation sheet Page 7 of 11 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 03/24/2025 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)

F 0692 Level of Harm - Minimal harm or potential for actual harm Resident R25's clinical record revealed an admission date of 3/11/25, with diagnoses that included high blood pressure, GERD, and alcohol induced cirrhosis of the liver. Resident R25's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Residents Affected - Some Resident R26's clinical record revealed an admission date of 3/7/25, with diagnoses that included COPD, depression, and high blood pressure. Resident R26's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Resident R27's clinical record revealed an admission date of 3/7/25, with diagnoses that included respiratory failure (a condition where you don't get enough oxygen or you get too much carbon dioxide in your body), COPD, and high blood pressure. Resident R27's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Resident R28's clinical record revealed an admission date of 3/13/25, with diagnoses that included diabetes, high blood pressure and left side paralysis. Resident R28's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Resident R29's clinical record revealed an admission date of 2/17/25, with diagnoses that included fractured vertebra, diabetes, and anxiety. Resident R29's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Resident R30's clinical record revealed an admission date of 3/5/25, with diagnoses that included dementia, high blood pressure, and depression. Resident R30's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Resident R31's clinical record revealed an admission date of 2/24/25, with diagnoses that included pneumonia, COPD, and diabetes. Resident R31's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Resident R32's clinical record revealed an admission date of 3/17/25, with diagnoses that included respiratory failure, GERD, and depression. Resident R32's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395363 If continuation sheet Page 8 of 11 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 03/24/2025 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)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident R33's clinical record revealed an admission date of 3/4/25, with diagnoses that included dementia, COPD, and Atrial Fibrillation (A-Fib - irregular and often rapid heart beat that can lead to stroke, heart failure, and other complications). Resident R33's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Resident R34's clinical record revealed an admission date of 3/10/25, with diagnoses that included high blood pressure, kidney failure (kidneys are no longer able to work therefore cannot filter waste and toxins from the blood), glaucoma (a group of diseases that damage the optic nerve which could lead to vision loss) Resident R34's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Resident R35's clinical record revealed an admission date of 3/10/25, with diagnoses that included fractured vertebra, anxiety, high blood pressure. Resident R35's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Resident 36's clinical record revealed an admission date of 3/3/25, with diagnoses that included pneumonia, COPD, and anxiety. Resident R36's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Resident R37's clinical record revealed an admission date of 2/12/25, with diagnoses that included broken left hip, depression, and arthritis. Resident R37's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Resident R38's clinical record revealed an admission date of 3/9/25, with diagnoses that included respiratory failure, COPD, and diabetes. Resident R38's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Resident R39's clinical record revealed an admission date of 2/2/25, with diagnoses that included heart attack, depression, and COPD. Resident R39's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Resident R40's clinical record revealed an admission date of 2/20/25, with diagnoses that included respiratory failure, COPD, and diabetes. Resident R40's clinical record lacked any evidence of a nutritional assessment being completed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395363 If continuation sheet Page 9 of 11 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 03/24/2025 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)

F 0692 within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Level of Harm - Minimal harm or potential for actual harm Resident R41's clinical record revealed an admission date of 3/8/25, with diagnoses that included broken right leg, dementia, high blood pressure. Residents Affected - Some Resident R41's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Resident R42's clinical record revealed an admission date of 2/25/25, with diagnoses that included kidney failure, dementia, A-Fib. Resident R42's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. Resident R43's clinical record revealed an admission date of 2/5/25, with diagnoses that included A-Fib, diabetes, and COPD. Resident R43's clinical record lacked any evidence of a nutritional assessment being completed within seventy-two hours of admission and/or throughout his/her stay at the facility at this time. During an interview on 3/17/25, at 10:05 a.m. the Director of Nursing stated that since the company changed ownership they have not had a dietitian. During an interview on 3/18/25, at 10:50 a.m. the Nursing Home Administrator (NHA) stated that the facility has been without a dietitian on a full-time, part-time, or consulting basis since 1/7/25. During an interview on 3/18/25, at 3:10 p.m. the NHA confirmed that there was no documented nutritional assessments for the above identified residents on admission or thereafter as required. The NHA further stated the facility has been without a dietitian since 1/07/25 and has not completed any nutritional assessments from 1/7/25 to the present on any residents. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(c) Resident care policies FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395363 If continuation sheet Page 10 of 11 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 03/24/2025 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)

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on review of employee credentials, and staff interviews, it was determined that the facility failed to ensure the employee designated as the full-time director of food and nutrition services, who was not a qualified dietitian or other clinically qualified nutritional professional, received frequently scheduled consultations from a qualified dietitian and/or failed to employ a full-time qualified dietitian since 1/7/25. Findings include: Review of the employee file/credentials the facility designated as the director of food and nutrition services revealed that he/she lacked the appropriate competencies and skills to function as the director to include any of the following: a certification for food service manager or a similar national certification for food service management and safety from a national certifying body or an associate's or higher degree in food service management or in hospitality or lacked two or more years experience in the position of food safety and completed a course study in food safety and management. There was no evidence that the facility had a dietitian functioning as a consultant for the employee designated as the director of food and nutrition services. During an interview with Director of Nursing (DON) on 3/17/25, at 10:05 a.m. the DON stated that since the company changed ownership they have not had a dietitian. During an interview with Nursing Home Administrator (NHA) on 3/18/25, at 10:50 a.m. the NHA stated that the facility has been without a dietitian on a full-time, part-time, or consulting basis since 1/7/25. 28 Pa Code 201.18(e)(1)(6) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395363 If continuation sheet Page 11 of 11