Health inspection·July 25, 2025

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 facility policies, clinical records and staff interviews, it was determined that the facility failed to take appropriate timely action to obtain a medication for one of 12 residents reviewed (Resident R1).Review of a facility policy entitled Administering Medication dated 12/2/24, indicated medications are administered in a safe and timely manner, as prescribed. Review of a facility policy entitled Medications Ordering and Receiving from Pharmacy dated 12/2/24, indicated medications and related products are received from the dispensing pharmacy on a timely basis. Review of facility policy entitled Medication orders dated 12/2/24, indicated a verbal prescription for a scheduled II medication may be called in to a pharmacist directly by the prescriber. The supply can be delivered from the pharmacy or may be available from the emergency kit. Review of Resident R1's clinical record revealed an admission date of 6/23/25, with diagnoses that included encounter for palliative care (care and comfort measures), hypertension (high blood pressure), and dementia (a disease that affects short term memory and the ability to think logically). Review of Resident R1's nursing documentation revealed that on 6/21/25, at 8:00 p.m. the facility staff called the hospital for an update on Resident R1. The hospital staff informed the facility that Resident R1 was placed under comfort measures only. Further review of nursing documentation revealed a note dated 6/23/35, at 3:54 p.m. that Resident R1 returned to the facility and upon return, Resident R1 was not responding to verbal or physical touch was having agonal (gasping and/or labored) breathing and received morphine before leaving the hospital. Review of Resident R1's clinical recorded revealed discharge orders from the hospital with an order for morphine 5-20 mg (milligrams) by mouth every 30 minutes for pain or dyspnea (difficulty breathing and/or shortness of breath). Review of Resident R1's facility physician's orders revealed an order dated 6/23/25, for morphine 20 mg per ml (milliliter) give 5 ml by mouth every 4 hours as needed. Review of Resident R1's admission/re-admission evaluation dated 6/23/25, revealed under the pain evaluation Does the patient have a diagnosis or disease condition that causes or is likely to cause pain or discomfort? The answer was marked as yes. Further review of Resident R1's admission/re-admission evaluation revealed a base line care plan for pain with an intervention to administer medication per physician's orders. Review of Resident R1's pain scale revealed on 6/23/25, at 10:51 p.m. a pain scale with advanced dementia (a pain scale where you observe signs of pain in a resident when they are unable to tell you their pain) was marked as 4 with details (observed signs of pain) of breathing score of a 2 for observations of noisy labored breathing, long period of hyperventilation, Cheyne-Stokes (an irregular breathing pattern) respiration and score of a 2 for observations of facial grimacing. Another pain scale with advanced dementia on 6/24/25, at 7:13 a.m. was marked as 4 with details of breathing score of a 2 for observations of noisy labored breathing, long period of hyperventilation, Cheyne-Stokes respiration and score of a 2 for observations of facial grimacing. Review of Resident R1's June 2025, medication administration record revealed that morphine was not given until 10:43 a.m. on 6/24/25. During an interview with Registered Nurse Employee E1, he/she revealed that it can take between 30 minutes to two hours to pull a controlled medication out of the facilities dispensing unit in the facility. He/she said that the process is to notify the physician and then the physician must speak to the pharmacist then the facility would receive a pull code (permission to remove a controlled medication from the dispensing unit). He/she expressed the time depends on the physician and pharmacist communication with each other. He/she also expressed that it may take longer depending on the day and/or time of day. During an interview on 7/25/25, at 1:00 p.m. with the Director of Nursing (DON) confirmed that the facility did not get a pull code for Resident R1's morphine until 6/24/25, at approximately 10:30 a.m. The DON confirmed that Resident R1 Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395363 If continuation sheet Page 2 of 4 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 07/25/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm returned to the facility with an order for morphine on 6/23/25. The DON also confirmed that Resident R1 had a pain scale of four on two different occasions prior to the morphine being obtained and that an as needed medication should be available and administered per physician's orders. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395363 If continuation sheet Page 3 of 4 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 07/25/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on review of facility policy and clinical record review and staff interview, it was determined that the facility failed to ensure that medication was obtained and provided as ordered by the physician for one of 12 residents reviewed (Resident R2). Review of facility policy entitled Administering Medications dated 12/2/24, indicated Medications are administered in accordance with prescriber orders, including any required time frame. Review of facility policy entitled Medication Orders dated 12/2/24, indicated The prescriber is contacted by nursing for directions when delivery of a medication will be delayed, or the medication is not or will not be available. Review of Resident R2's clinical record revealed an admission date of 4/8/25, with diagnoses that included diabetes (a health condition that caused by the body's inability to produce enough insulin), hypertension (high blood pressure), and Gastro Esophageal Reflux Disease (a condition when stomach acid repeatedly flows back up into your throat). Review of Resident R2's clinical record revealed a physician's order for caladryl external lotion 1-8% apply to rash topically two times a day for seven days dated 6/26/25. Review of his/her treatment record for the months of June and July 2025, lacked evidence that caladryl lotion was applied per physician's order. Review of nursing documentation revealed the facility was waiting delivery of the caladryl lotion from the pharmacy. During an interview on 7/25/25, at 1:05 p.m. the Director of Nursing (DON) confirmed that there was no documented evidence that the caladryl lotion was received from the pharmacy or applied to Resident R2 per physician order. The DON also confirmed that the caladryl lotion should have been obtained from pharmacy and applied per physician order. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. code 211.12(d)(1)(3)(5) Nursing services Event ID: Facility ID: 395363 If continuation sheet Page 4 of 4