Health inspection·August 21, 2025

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on review of clinical records and facility policy, observations, and staff interview, it was determined that the facility failed to appropriately maintain respiratory care equipment and promote cleanliness and help prevent the spread of infection regarding respiratory care equipment according to physician's orders for three of 25 residents reviewed (Resident R22, R55, and R120).Findings include: A facility policy entitled Oxygen dated 1/08/25, indicated that the humidifier (bottle of distilled water that adds moisture to the dry oxygen flow, preventing irritation and promoting comfort during inhalation) and tubing (tubing that connects the oxygen source (like a concentrator or tank), which then delivers the oxygen to the patient) will be changed and the concentrator (medical device that draws in room air, filters out nitrogen, and provides a concentrated stream of oxygen) filter will be cleaned every two weeks and as needed, and would be labeled with the date every time the humidifier/tubing is changed. Review of Resident R22's clinical record revealed an admission date of 2/19/24, with diagnoses that included respiratory failure, stroke with left-sided weakness, and metabolic encephalopathy (form of brain dysfunction caused by systemic illnesses, infections, toxins, or imbalances in the body's chemicals that affect brain function). Further review of Resident R22's clinical record revealed a physician's order dated 7/18/25, to administer ipratropium-albuteral solution (medication that relaxes and opens the air passages to the lungs to make breathing easier) through a nebulizer (small machine that turns liquid medicine into a mist that can be easily inhaled) by mouth three times a day for cough was discontinued on 7/20/25. Observation on 8/19/25, at 10:27 a.m. revealed a nebulizer machine on Resident R22's bedside stand and a nebulizer mask dated 7/26/25, lying on the floor between the bed and bedside stand. During an interview at that time, the Director of Nursing confirmed that the nebulizer mask and machine should have been removed from Resident R22's room upon the nebulizer order being discontinued. Resident R55's clinical record revealed an admission date of 6/12/23, with diagnoses that included heart failure, long-term kidney disease, and Type 2 Diabetes (condition where the body cannot use insulin correctly and sugar builds up in the blood). Further review of Resident R55's clinical record revealed a physician's order dated 12/30/23, to administer oxygen through a nasal cannula (thin, flexible tube that goes around your head with two prongs that go inside your nostrils that deliver the oxygen) to maintain blood oxygen saturations between 88-92%; a physician's order dated 3/18/24, to change oxygen tubing, water (humidifier) bottle, and clean the filter every two weeks. Review of Resident R55's treatment administration record (TAR) revealed that he/she received supplemental oxygen routinely. Observation on 8/19/25, at 10:50 a.m. revealed Resident R55's tubing bag was dated 8/05/25, the humidifier bottle was dated 8/11, there was no date on the oxygen tubing, and the external concentrator filter was covered with a copious amount of white fluffy substance. During an interview at that time, Licensed Practical Nurse (LPN) Employee E5 confirmed that the tubing bag and humidifier bottle should have been changed, the tubing should have been dated; and that the filter was dirty and needed cleaned/replaced. Resident R120's clinical record revealed an Residents Affected - Some (continued on next page) 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 4 Event ID: 395609 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 08/21/2025 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)