Health inspection·October 20, 2023

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, clinical records, and facility investigation, and staff interviews, it was determined that the facility failed to implement adequate safeguards in the locked dementia care unit to protect residents from abuse and physical altercation for two of 17 residents (Residents R25 and R94) resulting in actual harm of a laceration to the thumb and transport to the emergency room for treatment of sutures (stitches) for one Resident R94. Findings include: Review of the facility policy entitled, Staffing - [NAME] Lane dated 1/6/23, indicated that there will always be a minimum of two nursing staff on the hall when at least one resident is there. Review of facility policy entitled Resident Abuse, Neglect and Misappropriation of Property dated 1/6/23, indicated that it is the facility policy to prevent, report and investigate any and all allegations of abuse and neglect relative to all residents in the facility's care. The policy also revealed, that the definition of abuse will be defined per the CFR 488.301, 488.355 and the HCFA State Operations Manual Appendix P which defines abuse means the willful infliction of injury, .with resulting physical harm, pain, or mental anguish. Willful as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Review of CMS Guidelines 483.12 (a)(1) Freedom from Abuse, Neglect and Exploitation defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes .physical abuse . Also under the guidance under Abuse: Sections 1819 and 1919 of the Social Security Act provide that each resident has the right to be free from, among other things, physical or mental abuse and corporal punishment. The facility must provide a safe resident environment and protect residents from abuse. Review of Resident R25's clinical record revealed an admission date of 7/24/12, with diagnoses that included dementia (condition of impaired ability to remember, think, or make decisions that interferes with everyday activities), with behavioral disturbance, anxiety, depression and alcohol, cannabis and inhalant dependence, in remission. Review of Resident R25's Annual Minimum Data Set (MDS-a periodic assessment of resident care needs), dated 8/9/23, revealed under Section C: cognitive patterns, questions from C0500 BIMS Summary Score: Resident R25 scored a 9, indicating cognitive impairment. Review of a nursing note, dated 3/10/23, at 4:07 p.m. documented that Resident R25 had hands on another resident ripping the resident's shirt. Review of a nursing note, dated 7/23/23, at 8:20 p.m., revealed Resident R25 grabbed ahold of another resident's sweatshirt. Review of a nursing note, dated 8/16/23, at 7:00 p.m., revealed Resident R25 was noted holding a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395609 If continuation sheet Page 2 of 14 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 395609 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rouse Warren County Home 701 Rouse Avenue Youngsville, PA 16371 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 0600 closed fist and yelling at roommate in hallway. Level of Harm - Actual harm Review of Resident R25's clinical record revealed a nursing note, dated 8/19/23, revealed that Nurse Aide (NA) Employee E3 had come out of a resident room to find Resident R25 engaged in an altercation with Resident R94. Resident R25 was seated in the wheelchair and Resident R94 standing in front of Resident R25, both residents had grabbed each other's shirts with Resident R25's one hand held back as if preparing to punch Resident R94. NA Employee E3 was unable to separate the residents and called for assistance. Resident R25 had swelling and bleeding to inner right lower lip. Residents Affected - Few Review of Resident R94's clinical record revealed an admission date of 5/1/22, with diagnoses that included dementia (condition of impaired ability to remember, think, or make decisions that interferes with everyday activities), with behavioral disturbance, depression, cognitive impairment and high blood pressure. Review of Resident R94's Quarterly MDS, dated [DATE], revealed under Section C: cognitive patterns, questions from C0500 BIMS Summary Score: Resident R94 scored a 6, indicating severe cognitive impairment. Review of a nursing note, dated 7/7/23, at 5:04 p.m. revealed a NA observed Resident R94 strike another resident while ambulating beside the resident, punched with a closed fist to the other residents left upper arm. Review of a nursing note, dated 7/26/23, at 4:02 a.m. revealed that Resident R94 was having increased agitation tonight with another resident and staff. Resident refusing care yelling at staff and being confrontational with other residents in hallway. Review of Resident R94's clinical record revealed a nursing note, dated 8/19/23 at 10:58 p.m. that NA Employee E3 had come out of a resident room to find Resident R25 engaged in an altercation with Resident R94. Resident R25 was seated in the wheelchair and Resident R94 standing in front of Resident R25, both residents had grabbed each other's shirt's with Resident R25's one hand held back as if preparing to punch Resident R94, NA Employee E3 was unable to separate the residents and called for assistance. When assistance arrived they were able to separate the residents and Resident R94 stepped backward and fell onto his/ her buttocks. Review of information submitted by facility dated 8/20/23, revealed that on 8/19/23, Resident R25 had a physical altercation with Resident R94. When staff intervened to separate the residents, Resident R94 fell backwards onto their buttocks. Resident R25 had a split lip with bleeding and swelling to right lower lip. Resident R94 was taken to the emergency room for evaluation after the altercation with Resident R25. Review of a facility incident report, dated 8/19/23, revealed that Resident R94 was sent to the emergency room at 9:30 p.m. due to complaints of a two centimeter laceration to the right thumb, and received three sutures for the laceration, right side of face was red with superficial abrasions to bridge of nose, right temple and right upper eyelid. Resident R94's right eye was reddened and complained of pain to the right eye. Review of the facility investigation notes revealed that it was determined that staff left the hall and went to an adjoining unit for approximatley three and a half to four minutes, leaving the residents unattended. Upon return to the hall, this staff member intervened in the altercation. The staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395609 If continuation sheet Page 3 of 14 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 395609 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rouse Warren County Home 701 Rouse Avenue Youngsville, PA 16371 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 0600 member provided a witness statement with false information resulting in termination. Level of Harm - Actual harm During an interview on 10/19/23, at 11:00 a.m. the Nursing Home Administrator and Director of Nursing confirmed that NA Employee E3 willfully left the 300 hall (Willow Lane) without any staff on 8/19/23, for approximatley three and a half to four minutes when Resident R25 and Resident R94 were engaged in a physical altercation. Residents Affected - Few The facility failed to implement adequate safeguards to ensure residents are free from abuse for cognitively impaired residents in a locked dementia care unit resulting in actual harm of a laceration with sutures to Resident R94. 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 211.12(d)(3)(4)(5)Nursing services 28 Pa. Code 211.12(f.1)(1) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395609 If continuation sheet Page 4 of 14 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 395609 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rouse Warren County Home 701 Rouse Avenue Youngsville, PA 16371 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on review of Minimum Data Set (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care), clinical records, and staff interview, it was determined that the facility failed to ensure that MDS assessments accurately reflected the status for one of 24 residents reviewed (Resident R36). Residents Affected - Few Findings include: Review of MDS instructions for H0300 Urinary Continence indicated that urinary continence is to be coded as not rated if during the seven-day look-back period the resident had an indwelling bladder catheter (tubing from the bladder to drain urine into a bag), condom catheter, ostomy, or no urine output for the entire seven days. Review of Resident R36's clinical record revealed an admission date of 7/27/15, with diagnoses that included high blood pressure, diabetes, and pressure ulcer to the right buttocks. Review of Resident R36's clinical record revealed a physician's order dated 7/27/2023, for Foley Catheter to straight drainage. Resident R36's significant change MDS with an Assessment Reference Date of 8/18/23, was coded as always incontinent for urinary continence, although Resident R36 had an indwelling catheter for the entire seven-day look-back period. During an interview on 10/20/23, at 10:57 a.m. Registered Nurse Assessment Coordinator Employee E2 confirmed that the 8/18/23, MDS was coded inaccurately regarding urinary continence status for Resident R36. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f)(ix) Medical Records FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395609 If continuation sheet Page 5 of 14 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 395609 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rouse Warren County Home 701 Rouse Avenue Youngsville, PA 16371 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 an individualized comprehensive care plan to accurately reflect the resident's current condition for one of 24 residents reviewed (Resident R36). Findings include: Review of facility policy entitled Resident Care Plan dated 1/6/23, indicated that The Residents care plan must be kept current at all times and the approach / plan would include Individualized care for the unique needs of the resident. Review of Resident R36's clinical record revealed an admission date of 7/27/15, with diagnoses that included high blood pressure, diabetes, and pressure ulcer to the right buttocks. Review of Resident R36's clinical record revealed a physician's order dated 7/27/2023, for foley catheter (tubing inserted into the bladder to drain urine into a bag) to straight drainage. Review of Resident R36's comprehensive care plan revealed interventions for both an indwelling catheter and a suprapubic catheter (tube inserted surgically through the abdominal wall directly into the bladder to drain urine). During an interview on 10/20/23, at 10:57 a.m. Registered Nurse Assessment Coordinator Employee E2 confirmed that the care plan lacked individualized accurate interventions for the current catheter for Resident R36. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395609 If continuation sheet Page 6 of 14 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 395609 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rouse Warren County Home 701 Rouse Avenue Youngsville, PA 16371 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, facility documentation, and staff interview, it was determined that the facility failed to update the resident care plan with new interventions regarding physical behaviors for two of 24 residents (Residents R25 and Resident R94). Findings include: Review of information submitted by facility dated 8/20/23, revealed that on 8/19/23, Resident R25 had a physical altercation with Resident R94. When staff intervened to separate the residents, Resident R94 fell backwards onto their buttocks. Resident R25 had a split lip with bleeding and swelling to right lower lip. Resident R94 was taken to the emergency room for evaluation after the altercation with Resident R25. Review of a facility incident report, dated 8/19/23, revealed that Resident R94 was sent to the emergency room at 9:30 p.m. due to complaints of a two centimeter laceration to the right thumb, and received three sutures for the laceration, right side of face was red with superficial abrasions to bridge of nose, right temple and right upper eyelid. Resident R94's right eye was reddened and complained of pain to the right eye. Review of Resident R25's clinical record revealed an admission date of 7/24/12, with diagnoses that included dementia (condition of impaired ability to remember, think, or make decisions that interferes with everyday activities), with behavioral disturbance, anxiety, depression and alcohol, cannabis and inhalant dependence, in remission. Review of Resident R25's Annual Minimum Data Set (MDS-a periodic assessment of resident care needs), dated 8/9/23, revealed under Section C: cognitive patterns, questions from C0500 BIMS Summary Score: Resident R25 scored a 9, indicating cognitive impairment. Review of a nursing note, dated 3/10/23, at 4:07 p.m. documented that Resident R25 had hands on another resident ripping the resident's shirt. Review of a nursing note, dated 7/23/23, at 8:20 p.m., revealed Resident R25 grabbed ahold of another resident's sweatshirt. Review of a nursing note, dated 8/16/23, at 7:00 p.m., revealed Resident R25 was noted holding a closed fist and yelling at roommate in hallway. Review of Resident R25's clinical record revealed a nursing note, dated 8/19/23, revealed that Nurse Aide (NA) Employee E3 had come out of a resident room to find Resident R25 engaged in an altercation with Resident R94. Resident R25 was seated in the wheelchair and Resident R94 standing in front of Resident R25, both residents had grabbed each other's shirts with Resident R25's one hand held back as if preparing to punch Resident R94. NA Employee E3 was unable to separate the residents and called for assistance. Resident R25 had swelling and bleeding to inner right lower lip. Review of Resident R94's clinical record revealed an admission date of 5/1/22, with diagnoses that included dementia (condition of impaired ability to remember, think, or make decisions that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395609 If continuation sheet Page 7 of 14 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 395609 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rouse Warren County Home 701 Rouse Avenue Youngsville, PA 16371 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 interferes with everyday activities), with behavioral disturbance, depression, cognitive impairment and high blood pressure. Review of Resident R94's Quarterly MDS, dated [DATE], revealed under Section C: cognitive patterns, questions from C0500 BIMS Summary Score: Resident R94 scored a 6, indicating severe cognitive impairment. Review of a nursing note, dated 7/7/23, at 5:04 p.m. revealed a NA observed Resident R94 strike another resident while ambulating beside the resident, punched with a closed fist to the other residents left upper arm. Review of a nursing note, dated 7/26/23, at 4:02 a.m. revealed that Resident R94 was having increased agitation tonight with another resident and staff. Resident refusing care yelling at staff and being confrontational with other residents in hallway. Review of Resident R94's clinical record revealed a nursing note, dated 8/19/23 at 10:58 p.m. that NA Employee E3 had come out of a resident room to find Resident R25 engaged in an altercation with Resident R94. Resident R25 was seated in the wheelchair and Resident R94 standing in front of Resident R25, both residents had grabbed each other's shirt's with Resident R25's one hand held back as if preparing to punch Resident R94, NA Employee E3 was unable to separate the residents and called for assistance. When assistance arrived they were able to separate the residents and Resident R94 stepped backward and fell onto his/ her buttocks. Review of care plans for Resident R25 revealed a care plan focus issue resident has potential to demonstrate physical and verbal behaviors towards other residents that wander into his/her room and invade his/her personal space, dated 12/31/19, revealed interventions to guide away from source of distress, find resident a space to sit and monitor the environment away from intrusion, keep other residents away from residents room and communication , encourage seeking out staff member when agitated. Review of care plans for Resident R94 revealed care plan focus issue Behavior Care Plan resident will refuse care and has demonstrated physical and verbal aggression towards staff and other residents dated 9/27/23, revealed interventions of assist me to develop more appropriate methods of coping and interaction by redirection away from situations, staff or residents that may cause aggressive reactions. Review of the care plans lacked any new interventions related to the incident between Resident R25 and Resident R94 that occurred on 8/19/23 until 9/3/23 for Resident R25 (15 days later) and 9/27/23 for Resident R94 (39 days later). During an interview on 10/20/23, at 11:00 a.m. Social Worker Employee E4 confirmed that Residents R25 and Resident R94's careplans were not updated after the physical altercation. 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 211.12(d)(3)(4)(5)Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395609 If continuation sheet Page 8 of 14 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 395609 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rouse Warren County Home 701 Rouse Avenue Youngsville, PA 16371 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 and facility policy, observations, and staff interviews, it was determined that the facility failed to ensure an oxygen humidifier container was filled and changed according to facility policy and physician's order. Residents Affected - Few Findings include: Review of a facility policy entitled Oxygen Concentrators, most recently reviewed on 1/6/23, stated that Oxygen tubing and humidifier bottles must be changed every 14 days and PRN [as needed]. Review of Resident R1's clinical record revealed an admission date of 9/18/23, with diagnoses that included pneumonia, lung disease, kidney failure, high blood pressure and respiratory failure. Review of a physician's order dated 9/18/23, directed that Resident R41's oxygen tubing and humidifier be changed every two weeks, on Mondays. Observations on 10/17/23, at 2:47 p.m. revealed that Resident R41's disposable oxygen humidifier container was noted to be empty with a date of 10/3/23. The oxygen was in use at the time of the observation. At the time of the above observation, Licensed Practical Nurse Employee E10 confirmed that the humidifier container was empty and should have been previously changed. 28 Pa. Code 211.10(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: 395609 If continuation sheet Page 9 of 14 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 395609 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rouse Warren County Home 701 Rouse Avenue Youngsville, PA 16371 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, clinical records, and facility documentation, and staff interviews, it was determined that the facility failed to provide a safe environment by not providing adequate supervision to protect residents from injury during a resident to resident altercation between two of 17 residents (Residents R25 and R94), that resulted in actual harm of a laceration to the thumb and transport to the emergency room for treatment of sutures (stitches) for one resident (Resident R94). Findings include: Review of the facility policy entitled, Staffing - [NAME] Lane dated 1/6/23, indicated that there will always be a minimum of two nursing staff on the hall when at least one resident is there. Review of facility policy entitled Resident Abuse, Neglect and Misappropriation of Property dated 1/6/23, indicated that it is the facility policy to prevent, report and investigate any and all allegations of abuse and neglect relative to all residents in the facility's care. The policy also revealed, that the definition of abuse will be defined per the CFR 488.301, 488.355 and the HCFA State Operations Manual Appendix P which defines abuse means the willful infliction of injury, .with resulting physical harm, pain, or mental anguish. Willful as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Review of Resident R25's clinical record revealed an admission date of 7/24/12, with diagnoses that included dementia (condition of impaired ability to remember, think, or make decisions that interferes with everyday activities), with behavioral disturbance, anxiety, depression and alcohol, cannabis and inhalant dependence, in remission. Review of Resident R25's Annual Minimum Data Set (MDS-a periodic assessment of resident care needs), dated 8/9/23, revealed under Section C: cognitive patterns, questions from C0500 BIMS Summary Score: Resident R25 scored a 9, indicating cognitive impairment. Review of a nursing note, dated 3/10/23, at 4:07 p.m. documented that Resident R25 had hands on another resident ripping the resident's shirt. Review of a nursing note, dated 7/23/23, at 8:20 p.m. revealed Resident R25 grabbed ahold of another resident's sweatshirt. Review of a nursing note, dated 8/16/23, at 7:00 p.m. revealed Resident R25 was noted holding a closed fist and yelling at roommate in hallway. Review of a nursing note, dated 8/19/23, revealed that Nurse Aide (NA) Employee E3 had come out of a resident room to find Resident R25 engaged in an altercation with Resident R94. Resident R25 was seated in the wheelchair and Resident R94 standing in front of Resident R25, both residents had grabbed each other's shirt's with Resident R25's one hand held back as if preparing to punch Resident R94. NA Employee E3 was unable to separate the residents and called for assistance. Resident R25 had swelling and bleeding to inner right lower lip. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395609 If continuation sheet Page 10 of 14 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 395609 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rouse Warren County Home 701 Rouse Avenue Youngsville, PA 16371 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 0689 Level of Harm - Actual harm Review of Resident R94's clinical record revealed an admission date of 5/1/22, with diagnoses that included dementia (condition of impaired ability to remember, think, or make decisions that interferes with everyday activities), with behavioral disturbance, depression, cognitive impairment and high blood pressure. Residents Affected - Few Review of Resident R94's Quarterly MDS, dated [DATE], revealed under Section C: cognitive patterns, questions from C0500 BIMS Summary Score: Resident R94 scored a 6, indicating severe cognitive impairment. Review of a nursing note, dated 7/7/23, at 5:04 p.m. revealed a NA observed Resident R94 strike another resident while ambulating beside the resident, punched with a closed fist to the other residents left upper arm. Review of a nursing note, dated 7/26/23 at 4:02 a.m. revealed that Resident R94 was having increased agitation tonight with another resident and staff. Resident refusing care yelling at staff and being confrontational with other residents in hallway. Review of Resident R94's clinical record revealed a nursing note, dated 8/19/23 at 10:58 p.m. that NA Employee E3 had come out of a resident room to find Resident R25 engaged in an altercation with Resident R94. Resident R25 was seated in the wheelchair and Resident R94 standing in front of Resident R25, both residents had grabbed each other's shirt's with Resident R25's one hand held back as if preparing to punch Resident R94, NA Employee E3 was unable to separate the residents and called for assistance. When assistance arrived they were able to separate the residents and Resident R94 stepped backward and fell onto his/ her buttocks. Review of information submitted by facility dated 8/20/23, revealed that on 8/19/23, Resident R25 had a physical altercation with Resident R94. When staff intervened to separate the residents, Resident R94 fell backwards onto their buttocks. Resident R25 had a split lip with bleeding and swelling to right lower lip. Resident R94 was taken to the emergency room for evaluation after the altercation with Resident R25. Review of a facility incident report, dated 8/19/23, revealed that Resident R94 was sent to the emergency room at 9:30 p.m. due to complaints of a two centimeter laceration to the right thumb, and received three sutures for the laceration, right side of face was red with superficial abrasions to bridge of nose, right temple and right upper eyelid. Resident R94's right eye was reddened and complained of pain to the right eye. Review of the facility investigation notes revealed that it was determined that staff left the hall and went to an adjoining unit for approximatley three and a half to four minutes, leaving the residents unattended. Upon return to the hall, this staff member intervened in the altercation. The staff member provided a witness statement with false information resulting in termination. During an interview on 10/19/23, at 11:00 a.m. the Nursing Home Administrator and Director of Nursing confirmed that NA Employee E3 left the 300 hall (Willow Lane) unsupervised without any staff on 8/19/23, for approximatley three and a half to four minutes when Resident R25 and Resident R94 were engaged in an altercation. The facility failed to implement adequate supervision to protect cognitively impaired residents from a physical altercation in a locked dementia care unit resulting in actual harm of a laceration (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395609 If continuation sheet Page 11 of 14 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 395609 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rouse Warren County Home 701 Rouse Avenue Youngsville, PA 16371 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 0689 requiring sutures to Resident R94. Level of Harm - Actual harm 28 Pa. Code 201.14(a) Responsibility of licensee Residents Affected - Few 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(d)(3)(4)(5)Nursing services 28 Pa. Code 211.12(f.1)(1) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395609 If continuation sheet Page 12 of 14 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 395609 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rouse Warren County Home 701 Rouse Avenue Youngsville, PA 16371 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 - Few 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 policy and clinical records, observations and staff interview, it was determined that the facility failed to provide appropriate care and services regarding a urinary catheter (a tube placed into the bladder to drain urine into a bag) for one of 24 residents reviewed (Resident R29). Findings include: Review of facility policy regarding indwelling urinary catheters dated January 6, 2023, indicated to properly position catheter drainage bag below level of the bladder and it must not touch the floor. Review of Resident R29's Significant Change Minimum Data Set (MDS-a mandated assessment of a residents abilities and care needs) assessment, dated August 30, 2023, revealed that the resident was cognitivly impaired, unable to make their needs known, required extensive assistance for daily care, and had an indwelling urinary catheter. Observations in Resident R29's room on October 18, 2023, at 10:20 a.m. revealed that the resident's urinary drainage bag and tubing were lying on the floor without a cover over the drainage bag. During an interview on October 18, 2023, at 10:40 a.m. the Director of Nursing on confirmed that Resident R29's urinary drainage bag and tubing should not have been on the floor and should have a cover over the drainage bag. 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.10(c)(d) Resident care policies FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395609 If continuation sheet Page 13 of 14 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 395609 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rouse Warren County Home 701 Rouse Avenue Youngsville, PA 16371 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Based on review of facility policy, facility documentation, clinical records and staff interview it was determined that the facility failed to provide accurate and timely documentation related to offering the COVID-19 vaccine and providing education for one of five residents reviewed for immunizations (Resident R55). Findings include: Review of facility policy entitled Immunizations (Resident) with a review date of 4/19/2023, revealed, all residents (families/POA's, etc.) will be given education about the vaccine being offered that will be directly from the CDC. This education will include benefits and potential side effects. Review of Resident R55's clinical record revealed there was no evidence of education provided to the Power of Attorney (POA) regarding immunization related to the COVID-19 vaccine in the immunization portion of the clinical record. Review of Resident R55's clinical record revealed that the Resident's POA refused the COVID-19 vaccine for the resident. There was no evidence of education documented of the positive and adverse affects of the COVID-19 vaccine in Resident R55's record. During an interview on 10/20/2023, at 11:09 a.m. the Infection Preventionist confirmed that there was no education documented in Resident R55's clinical record. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 201.18(b)(1)(e)(1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395609 If continuation sheet Page 14 of 14