Health inspection·December 11, 2025

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure physician orders, residents' Physician Order for Life Sustaining Treatment (POLST- a legal document specifying the resident/responsible party choices regarding life-sustaining treatments), electronic health record (EHR), and paper charts were consistent for two of 18 residents reviewed (Residents R9 and R52).Findings include: The facility policy entitled Advance Directives dated [DATE], indicated that The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive.The Director of Nursing (DON) or designee will notify the Attending Physician of advance directives so that the appropriate orders can be documented in the resident's medical record and plan of care. Resident R9's clinical record revealed an admission date of [DATE], with diagnoses that included hemiplegia affecting the right dominant side (paralysis on one side of the body), dysphagia (difficulty swallowing), and hypertension (high blood pressure). Resident R9's physician orders and EHR dated [DATE], revealed an order for cardiopulmonary resuscitation (CPR-emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after cardiac arrest)-Full code. Resident R9's paper chart revealed a Do Not Resuscitate (DNR) form dated [DATE], with a bright DNR sticker in the front of the paper chart and deeper within the paper chart a POLST dated [DATE], that revealed Resident R9 requested CPR/Attempt Resuscitation. Resident R52's clinical record revealed an admission date of [DATE], with diagnoses that included chronic obstructive pulmonary disease (progressive lung disease that blocks airflow, causing breathing difficulties), heart failure, and irregular heartrate. Resident R25's physician orders and EHR dated [DATE], revealed an order for CPR-Full code. Resident R25's paper chart revealed a POLST dated [DATE], that revealed Resident R25 requested DNR. During an interview on [DATE], at 11:15 a.m. the DON, confirmed Residents R9 and R52's, physician's orders, POLST, EHR, and paper charts information were not consistent with each other.28 Pa. Code 201.18 (b)(1)(e)(1) Management 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.5(f)(i)(vii) Medical records 28 Pa. Code 211.10(c) Resident care policies 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 3 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 12/11/2025 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)