Health inspection·September 27, 2024

F 0625 Level of Harm - Minimal harm or potential for actual harm was no evidence that the residents listed above and/or their representatives were provided with a copy of the facility bed-hold policy and also confirmed that the bed-hold policy should have been provided upon transfer. 28 Pa. Code 201.18(e)(1) Management Residents Affected - Some 28 Pa. Code 201.29(c.3) (2) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395609 If continuation sheet Page 2 of 8 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 09/27/2024 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 clinical records, the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of three of 24 residents reviewed (Residents R78, R72, and R99). Residents Affected - Some Findings include: Review of Section O0110 of the RAI User's Manual entitled Special Treatments, Procedures, and Programs directs staff to Check all of the following treatments, procedures, and programs that were performed (a) on admission- days one through three, (b) while a resident- within the last 14 days, (c) at discharge- last three days of the resident's stay. Review of Section I of the RAI User's Manual entitled Active Diagnoses in the Last 7 days directs staff to Check the following information sources in the medical record for the last 7 days to identify active diagnoses: transfer documents, physician progress notes, recent history and physical, recent discharge summaries, nursing assessments, nursing care plans, medication sheets, doctor's orders, consults and official diagnostic reports, and other sources as available. Resident R78's clinical record revealed an admission date of 5/05/21, with diagnoses that included arthritis, neuropathy (nerve damage outside the brain and spinal cord that causes pain or numbness), depression, anxiety, hearing loss, difficulty swallowing, and injury of the facial nerve. Review of R78's Quarterly MDS with an Assessment Reference date (ARD) of 6/10/24, revealed Section O0110E1 (tracheostomy care- a surgical procedure that creates an opening in the neck into the windpipe (trachea) to allow air to flow into the lungs) was coded b (while a resident) therefore indicating Resident R78 had a tracheostomy. Observation on 9/25/24, at 9:58 a.m. revealed Resident R78 lacked visual evidence of a tracheostomy, and during an interview at that time Resident R78 confirmed that he/she never had a tracheostomy. Resident R72's clinical record revealed an admission date of 4/27/20, with diagnoses that included muscle weakness, anxiety, dementia (memory loss that interferes with daily living), and difficulty walking. Review of R72's Comprehensive MDS with an ARD of 7/01/24, revealed that Section I5950 Psychotic Disorder (other than schizophrenia) was incorrectly marked as an active diagnosis for Resident R72. Resident R99's clinical record revealed an admission date of 11/22/22, with diagnoses that included weakness, dementia, and hyperlipidemia (high cholesterol). Review of R99's Quarterly MDS with an ARD of 7/29/24, revealed Section I5950 Psychotic Disorder (other than schizophrenia) was incorrectly marked as an active diagnosis for Resident R99. During an interview on 9/26/24, at 10:02 a.m. the Registered Nurse Assessment Coordinator (RNAC) confirmed that Resident R78's 6/10/24, quarterly MDS Section O0110E1 was coded incorrectly and during an interview on 9/27/24, at 10:36 a.m. the RNAC confirmed that Resident R72's comprehensive MDS (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395609 If continuation sheet Page 3 of 8 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 09/27/2024 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 section I5950 and R99's quarterly MDS section I5950 were also coded incorrectly. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(5) Nursing services Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395609 If continuation sheet Page 4 of 8 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 09/27/2024 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and clinical record, and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for one of 24 residents reviewed (Resident R55). Findings include: A facility policy entitled, 48-Hour Care Plan dated 1/06/24, revealed It is the policy of Rouse [NAME] County Home to provide the resident and family with baseline care plan that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Procedure: RNAC (Registered Nurse Assessment Coordinator) 6. Reviews 48-hour care plan for completion and provides copy to resident/family in resident room. Document in record that resident was given copy. Review of Resident R55's clinical record revealed an admission date of 5/22/24, with diagnoses that included dementia (a disease that affects short term memory and the ability to think logically), hypertension (high blood pressure), and hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones). Review of R55's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R55 and/or his/her representative. During an interview on 9/26/24, at 2:00 p.m. the Director of Nursing (DON) confirmed that the clinical record for Resident R55 lacked evidence that a written summary of the baseline care plan and order summary was provided to the resident and/or his/her representative upon admission to the facility. 28 Pa. Code 211.10(c) Resident care policies FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395609 If continuation sheet Page 5 of 8 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 09/27/2024 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 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. Based on review of facility policy and clinical record, and staff interview, it was determined that the facility failed to include reconciliation of all pre-discharge medications with the resident's post-discharge medications in the resident's discharge summary, for one of two closed records reviewed (Closed Record Resident CR122). Findings include: Review of a facility policy entitled, Discharge of Resident dated 1/06/24, revealed that discharge medications will be listed in the Discharge Planning & Instructions assessment section medications. This will include the name of medication, dose, directions for use and quantity. Review of Resident CR122's clinical record revealed an admission date of 10/09/23, with diagnoses that included, dementia (a disease that affects short term memory and the ability to think logically), high blood pressure, depression, anxiety, and weakness. Resident CR122's clinical record also revealed a discharge date of 8/03/24. Review of the discharge summary lacked evidence of reconciliation of discharge medications on discharge. Review of nursing documentation lacked evidence of the type or number of medications sent home with Resident CR122 on discharge. During an interview on 9/27/24, at 11:30 a.m. the Director of Nursing (DON) confirmed there was no documentation of what medications or number of medications that were sent home with Resident CR122. The DON also confirmed that discharge medications should have a reconciliation of type of medication and amount of medications on the discharge summary. 28 Pa. Code 211.9(j.4) Pharmacy services 28 Pa. Code 211.5(f)(x) Medical records FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395609 If continuation sheet Page 6 of 8 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 09/27/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on review of facility policyand manufacturer's guidelines, observations, and staff interview, it was determined that the facility failed to ensure that medications were properly dated when opened and discarded in a timely manner in one of four medication rooms reviewed (central medication storage room). Findings include: Review of a facility policy entitled Medication Administration General Guidelines dated 1/06/24, revealed, When opening a new multi-dose bottle, the bottle must be dated and initialed. Manufacturer's guidelines for Tubersol PPD (solution used for tuberculosis testing upon admission and for employment), indicated that vials which are entered and in use for 30 days should be discarded. Observations of drug storage on 9/25/24, at approximately 9:26 a.m. in the central medication storage room refrigerator revealed two opened vials of Tubersol without an open date, therefore the staff were unable to determine the discard date. During an interview at that time Licensed Practical Nurse Employee E1 confirmed that the two opened Tubersol vials lacked an open date and staff were unable to determine the discard date. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395609 If continuation sheet Page 7 of 8 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 09/27/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to maintain accurate clinical records for two of 24 residents reviewed (Residents R48 and R116). Residents Affected - Few Findings include: A facility policy entitled, admission Policy dated 1/06/24, revealed that medical records from the referring agencies and discharge orders are given to the Medical Records office at the Rouse Home and uploaded to the resident chart. Review of Resident R48's clinical record revealed an admission date of 4/17/24, with diagnoses that included heart failure, diabetes, dysphagia (difficulty swallowing), depression and anxiety. Review of Resident R48's clinical record diagnoses list revealed that on 3/06/24, a diagnosis of Post Traumatic Stress Disorder (PTSD-a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event, series of events or set of circumstances) was added Further review of Resident R48's clinical record revealed psychiatric consult notes from 3/06/24, 5/22/24 and 8/22/24, all which lacked evidence of a diagnosis of PTSD. During interview on 9/27/24, at 10:30 a.m. the Director of Nursing confirmed that Resident R48's clinical record had no evidence of a diagnosis of PTSD from a licensed practitioner. Resident R116's clinical record revealed an admission date of 4/26/24, with diagnoses that included diverticulosis (condition where small pouches, or diverticuli, form in the walls of the gastrointestinal tract) of the large intestine, urinary tract infection, heart disease, dementia, and PTSD. Further review revealed that Resident R116's clinical record erroneously contained pre-admission information from a referring agency for another potential resident. During an interview on 9/27/24, at 9:29 a.m. the Director of Social Services confirmed that Resident R116's clinical record contained information for another potential resident and should not have been uploaded into Resident R116's clinical record. 28 Pa. Code 211.12(d)(1) Nursing Services 28 Pa. Code 211.5(f)(v) Medical records FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395609 If continuation sheet Page 8 of 8