Pennsylvania Department of Health
ROUSE- WARREN COUNTY HOME
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

ROUSE- WARREN COUNTY HOME
Inspection Results For:

There are 102 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


ROUSE- WARREN COUNTY HOME - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance Survey, and an Abbreviated Complaint Survey completed on August 7, 2026, it was determined that Rouse Warren County Home was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Observations:

Based on review of a facility policy, observations, and staff interview, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety in the main kitchen and two kitchenettes observed (kitchenettes 100 hall and 400 hall).

Findings include:

Review of facility policy entitled "Date marking and Discarding of Food" dated 1/5/26, revealed "If there is a use by date on a product and the product is unopened this is the date you follow. If you open a food item ..., the use by date is 3 days from the date that it was open. Leftover food may be saved for 3 days after preparation."

Review of the med pass supplement label revealed "After open, consume product within 4 days if properly refrigerated."

Observations during tour of the main kitchen on 8/4/26, at 11:50 a.m. revealed the following: in the dry storage room a bag of Oreo cookie crumbles with a best buy date of 5/11/26; in the first walk-in refrigerator revealed three metal pans the first pan contained prepared peas with a date of 7/30/26; the second pan contained prepared mixed vegetables with a date of 7/31/26; and the third pan contained prepared chicken with a date of 7/29/26; in the second walk-in refrigerator revealed three cartons of whip cream one opened, all with best buy dates of 7/31/26, an open package of corn beef lunch meat with an open date of 7/21/26, and an open container of horseradish with a best by date of 7/6/26.

During an interview at the time of observation with the Dietary Manager, he/she confirmed that the Oreo cookie crumble, the peas, mixed vegetables, chicken, three containers of whip cream, package of corn beef lunch meat, and the container of horseradish were beyond their use by dates and should have been discarded.

Observations on 8/5/26, at 9:43 a.m. of the 100-hall kitchenette refrigerator revealed and open container of med pass (a supplement given to residents during medication administration) with an open date of 7/18/26.

During an interview on 8/5/26, at the time of observations Licensed Practical Nurse Employee E8 confirmed that the med pass was dated open on 7/18/26, which was beyond its use by date and should have been discarded.

Observations on 8/5/26, at 9:50 a.m. of the 400-hall kitchenette refrigerator revealed an open half gallon of lactose free milk with a best buy date of 8/1/26, and a half gallon of regular milk with a best buy date of 8/4/26.

During an interview on 8/5/26, at the time of observation Registered Nurse Employee E9 confirmed that the lactose free milk and the regular milk were beyond their use by dates and should have been discarded.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(1) Management

Plan of Correction - To be completed: 09/22/2026

During survey conducted 8/4-8/7 2026 expired/outdated food items were identified in the dietary department dry storage, walk-in coolers, and kitchenette refrigerators on 100 Hall and 400 Hall.
Immediate corrective action:
Upon identification of deficiency all expired, outdated food items were immediately removed from service and discarded.
Food remaining in storage was checked for dates, labeling, date opened and/or prepared, appropriate storage, and proper rotation.
The Food Services Director reviewed the findings with all dietary staff and reiterated the facility policy for storage and dating/labeling requirements.
Changes To Prevent Recurrence
The Food Services Director or designee will re-educate the Dietary staff on the facility policy for storage and dating/labeling, which includes checking expiration/use-by dates on a daily basis, proper storage, labeling and dating of open, prepared, and leftover food and beverage items, Identification and removal of expired or outdated items.
The Food Services Director or designated person will conduct daily checks for four (4) weeks of the main kitchen and nursing unit food storage areas.
Daily checks will be added to chore list for dietary staff to monitor the main kitchen and all nursing unit food storage areas daily going forward.
The results of the daily food storage audits and any identified trends or areas of non-compliance will be reviewed by the Food Service Director. Audit findings, corrective actions, and ongoing compliance will be reported to the facility's Quality Assurance and Performance Improvement (QAPI) Committee.
The QAPI Committee will review the monitoring results to identify trends and determine whether additional corrective actions or interventions are necessary to ensure sustained compliance. The frequency and duration of ongoing monitoring will be determined by the QAPI Committee based on audit findings and demonstrated compliance.

483.10(c)(1)(4)(5) REQUIREMENT Right to be Informed/Make Treatment Decisions:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.10(c) Planning and Implementing Care.
The resident has the right to be informed of, and participate in, his or her treatment, including:

§483.10(c)(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition.

§483.10(c)(4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care.

§483.10(c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers.

Observations:

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to inform the resident and/or resident representative in advance of the risks and benefits of psychotropic medications (medications that affect the persons mental state, emotions and behavior) and the treatment alternatives prior to initiating the administration of the medication for one of five residents reviewed for unnecessary medications (Resident R11).

Findings include:

Facility policy entitled "Psychotropic Medications" dated 1/5/26, indicated that the facility will inform the resident's representative of the need for desired effects and potential side effects of medication. RN (Registered Nurse) will obtain consent either, verbally or in person, and complete Psychotropic Medication Consent form.

Resident R11's clinical record revealed an admission date of 2/11/24, with diagnoses that included Diabetes (a health condition caused by the body's inability to produce enough insulin), Dementia (loss of cognitive functioning affecting a person's memory and behaviors), and Congestive Heart Failure (CHF - a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply causing blood and fluids collect in your lungs and legs over time).

Resident R11's physician's orders revealed an order dated 4/21/26, for Diazepam (medication used to treat anxiety) 5 milligram (mg) by mouth twice daily for 90 days and a second order dated 6/17/26, for Diazepam 5 mg by mouth daily and 10 mg by mouth at bedtime. Resident R11's clinical record lacked evidence that he/she and/or his/her representative were informed in advance of the risks, benefits, and alternative treatments prior to the administration of Diazepam.

During an interview on 8/7/26, at 9:53 a.m. the Director of Nursing confirmed that Resident R11's clinical record lacked evidence that he/she and/or his/her representative were informed in advance of the risk, benefits, and alternative treatment prior to the administration of Diazepam.

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

28 Pa. Code 201.18(b)(1) Management

Plan of Correction - To be completed: 09/22/2026

The facility obtained the required consent for the resident's (R11) psychotropic medication from the resident and/or legally authorized representative. Education regarding the ordered psychiatric medication, including the medication name, purpose, dosage, frequency, expected benefits, potential side effects, and risk. All questions answered.

Administrator or Social Service designee will review all current residents receiving psychotropic medications to verify that required informed consent is present and properly documented. Any missing consent will be obtained promptly from the resident and/or legally authorized representative, as applicable.

Administrator, Director of Resident Centered Services or designee will provide education to all licensed nursing staff regarding the facility's informed-consent process for psychotropic medications. Staff will be instructed to ensure that consent is obtained and documented before initiation of the medication, when required, and that the medical record contains the appropriate signed consent.

Administrator or Social Service designee will audit all new psychotropic medication orders weekly for four weeks and monthly for three months to verify that the required consent is obtained, signed, and documented in the medical record. Audit findings will be reviewed through the facility's Quality Assurance/Performance Improvement process. Any identified variance will be immediately corrected and additional education provided as indicated.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.71 and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.

Observations:

Based on review of facility policy and clinical record, observations, and staff interview, it was determined that the facility failed to follow acceptable infection control practices regarding enhanced barrier precautions (EBP) for one of 27 residents reviewed (Resident R76) on the 400 unit (memory care unit.)

Findings include:

Review of a facility policy entitled, "Isolation Precautions (Contact, Droplet, Airborne)," dated 1/01/26, revealed it is the policy of this facility to "prevent and limit the spread of infection within the facility through the use of isolation precautions while providing care to those that require isolation precautions." The policy further stated that "An orange sign instructing visitors to report to the nursing station before entering should be placed at the doorway of the resident's room.

Isolation precautions refer to the use of gown and gloves for certain residents during specific high-contact resident care activities that have been found to increase risk for transmission of multidrug-resistant organisms. Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves. An order for enhanced barrier precautions will be obtained for residents with any of the following: Wounds and/or indwelling medical devices (e.g., central line, urinary catheter [a tube inserted into the bladder to drain urine], feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status.

Resident R76's clinical record revealed an admission date of 1/12/26 with diagnoses of dysphagia (difficulty swallowing), difficulty in walking, abnormal posture and hypertension (high blood pressure). The clinical record also revealed an alert that the resident was on isolation precautions due to an eye inflammation which had been cultured with results pending.

Observations on 8/04/26, 8/05/26, and 8/06/26, revealed no educational alert signage or PPE maintained for Resident R76 at the doorway of the resident room on the memory care unit, identified as being on "contact precautions" to alert nursing staff and visitors of potential infectious exposure.

During an interview on 8/06/26, at 11:30 a.m. Licensed Practical Nurse Employee E4 confirmed the facility lacked signage for a resident with contact precautions who should have isolation precautions maintained.

28 Pa. Code 211.10(c) Resident care policies

28 Pa. Code 211.12(d)(1)(5) Nursing services

Plan of Correction - To be completed: 09/22/2026

The precaution signage for the identified resident was immediately placed outside the resident's room to clearly identify the required precaution and PPE prior to room entry. No adverse outcome to the resident was identified related to the missing signage.
The Infection Preventionist immediately conducted a review of all residents currently requiring Transmission-Based Precautions and/or Enhanced Barrier Precautions. Each applicable resident's room was inspected to verify that appropriate precaution signage was posted, visible, current, and consistent with the needs of the resident. Any identified discrepancies were corrected immediately.

Nursing staff will be re-educated on the facility's Infection Prevention and Control/Isolation Precaution policy, including the requirement that appropriate precaution signage be posted outside the resident's room immediately upon initiation of precautions and remain in place for the duration of the precaution.
Education will include verification of the type of precaution, required PPE, and the responsibility of nursing staff to notify the nurse/charge nurse or Infection Preventionist when signage is missing, inaccurate, or removed.
Staff will also be reminded that precaution signage serves as an immediate visual cue to staff, physicians, ancillary personnel, and visitors regarding the precautions that must be followed prior to entering the resident's room. New signage will be created and educated with staff for use on the dementia unit to reduce the probability of signage being taken down by residents.

The Infection Preventionist or designee will conduct audits of all residents requiring Transmission-Based Precautions and/or Enhanced Barrier Precautions daily for 1 week, weekly for 4 weeks, and monthly for 2 months thereafter. Audits will verify that:
Appropriate precaution signage is present and clearly visible outside the resident's room;
o Signage accurately reflects the resident's current precaution status;
o Required PPE is readily available;
o Physician orders and care plans are consistent with the precautions in place; and
o Staff appropriately follow the precautions and PPE requirements.
Any identified deficiency will be corrected immediately, with re-education provided as indicated.

Audit results will be reviewed by the Infection Preventionist and reported to the Quality Assurance and Performance Improvement (QAPI) Committee. Trends or repeated concerns will be evaluated, and additional corrective actions and/or monitoring will be implemented as necessary to ensure sustained compliance.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Observations:

Based on review of facility policy, manufacturer's recommendations, observations, and staff interviews, it was determined that the facility failed to ensure that medications and stock supplements were properly dated when opened and discarded in a timely manner two of five medication carts reviewed (Unit 100 and Unit 700).

Findings include:

Review of a facility policy entitled "Medication Administration General Guidelines" dated 1/05/26, revealed it is the policy to administer medications as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. Always check manufacturer's expiration date prior to administration and discard expired medications per policy.

Review of a facility policy entitled "House-Supplied (Floor Stock) Medications" dated 1/05/26, revealed the facility will use the manufacturer's expiration date to determine when the medication is to be disposed of due to expired date.

Manufacturer's recommendations for Insulin Lispro Kwikpen (a type of fast-acting insulin), revealed to throw away the Insulin Lispro pen you are using after 28 days, even if it still has insulin left in it.

Manufacturer's recommendations for UTI-Stat (a supplement to prevent a urinary tract infection) 30 fl oz (fluid ounces) revealed discard three months after opening and record date opened on bottom of container.

Observations of the 100 Unit's medication cart on 8/04/26, at 12:30 p.m. revealed an opened Kwikpen of Insulin Lispro without an open date, therefore the staff were unable to determine the discard date. Licensed Practical Nurse (LPN) Employee E5 confirmed at that time, that the opened Insulin Kwikpen lacked an open date, and staff were unable to determine the discard date for safety of use of the insulin.

Observations of the 700 Unit's medication cart on 8/04/26, at 2:50 p.m. revealed an opened bottle of UTI-Stat with no open date, therefore the staff were unable to determine the discard date. The manufacturer instructions noted on the bottle revealed to discard 3 months after opening. LPN Employee E6 confirmed at that time, that there was no open date documented on the bottle, and staff were unable to determine the discard date for safety of use of the UTI-Stat supplement.

Interview with the Director of Nursing on 8/05/26, at approximately 2 p.m. revealed it is the facility policy to always date insulin and supplements when opened to ensure safety when administering to a resident.

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

Plan of Correction - To be completed: 09/22/2026

The undated insulin pen along with undated bottle of UTI Stat were discarded upon finding. An audit was completed on all medication carts and medication storage areas immediately following, no other medications found out of compliance.
The DON/RN Educator to complete LPN and RN staff re-educated on the facility policy "Medication Administration General" with a focus on proper labeling of opened multi-dose medications.
DON/Designee will audit all medication carts in use for open dates and or expiration dates will be conducted weekly x 4 weeks, bi-weekly x 4 weeks and monthly x 1.
The results of the audits will be reported by the Administrator/ Designee to the Quality Assurance Performance Improvement committee. The committee will evaluate and make further recommendations as indicated.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:

§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Observations:

Based on review of facility policy, clinical records, observation, and staff interview, it was determined that the facility failed to maintain proper care of respiratory equipment according to physician's orders for two of five residents reviewed for respiratory care (Residents R18 and R20).

Findings include:

Review of facility policy entitled "Medication Administration General Guidelines" dated 1/5/26, indicated "Medications are administered in accordance with written orders of the attending physician."

Review of Resident R18's clinical record revealed an admission date of 2/21/25, with diagnoses that included chronic respiratory failure (a condition where your lungs don't exchange air properly), chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), and hypertension (high blood pressure).

Review of Resident R18's physician's orders dated 10/20/25, revealed an order to change O2 (oxygen) tubing (a thin tube with two prongs that fit into the resident's nostrils to deliver oxygen), water bottle (used to humidify the oxygen being delivered to prevent drying of the nares), and tubing bag (a zip lock type bag to store the oxygen tubing when not in use) weekly every night shift every Sunday.

Observation on 8/4/26, at 2:00 p.m. revealed an oxygen concentrator sitting next to Resident R18's bed and attached to the concentrator was a water bottle and O2 tubing with a date of 7/27/26, written on them. Observation on 8/5/26, at 9:30 a.m. of the water bottle and O2 tubing attached to the oxygen concentrator remained with a date of 7/27/26 (Monday).

Review of Resident R20's clinical record revealed an admission date of 8/21/23, with diagnoses that included chronic obstructive pulmonary disease,gastro esophageal reflux disease (a condition when stomach acid repeatedly flows back up into your throat), and hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones).

Review of Resident R20's physician orders revealed an order dated 10/20/25, to change O2 tubing, water bottle, and tubing bag weekly every night shift every Sunday.

Observation on 8/4/26, at 2:00 p.m. revealed an oxygen concentrator sitting next to Resident R20's bed and attached to the concentrator was a water bottle and O2 tubing with a date of 7/27/26, written on them. Observation on 8/5/26, at 9:30 a.m. of the water bottle and O2 tubing attached to the oxygen concentrator remained with a date of 7/27/26 (Monday).

During an interview on 8/5/26, at 2:29 p.m. the Director of Nursing (DON) confirmed that Resident's R18 and R20's water bottle and oxygen tubing were dated 7/27/26. The DON also confirmed that Resident's R18 and R20's water bottles and oxygen tubing should have been changed per physician orders.

28 Pa. Code 211.12(d)(1)(5) Nursing services

28 Pa. Code 211.10(c) Resident care policies

Plan of Correction - To be completed: 09/22/2026

The facility cannot retroactively correct deficiency. R18 and R20 O2 tubing and oxygen humidifier was replaced and dated immediately at time identified. All residents with 02 orders were inspected to ensure proper dated tubing and humidifier in place. No other resident identified out of compliance.
Infection Preventionist/ADON completed Staff re-education on proper replacement and dating of O2 tubing and humidification weekly per Physician order and Policy IC-5 Oxygen.
DON/Designee will conduct audits on all residents utilizing oxygen. Audits will consist of checking for proper labeling, storage and replacement as outlined in Physician order and policy IC-5 Oxygen. Weekly audits will be completed for four weeks, Biweekly audits for four weeks, then monthly for 1 month.
Audit findings will be reviewed by the Administrator and/or Quality Assurance/Performance Improvement (QAPI) Committee. The monitoring process will continue until sustained compliance is demonstrated.

483.20(e)(1)(2) REQUIREMENT Coordination of PASARR and Assessments:

§483.20(e) Coordination.
A facility must coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort. Coordination includes:

§483.20(e)(1)Incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care.

§483.20(e)(2) Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment.

Observations:

Based on a review of clinical records and staff interviews, it was determined that the facility failed to refer residents with newly evident or possible serious mental disorders, intellectual disabilities, or related conditions for a Preadmission Screening and Resident Review (PASRR) level II resident review for one of 27 residents reviewed (Resident R10).

Findings include:

Preadmission Screening and Resident Review (PASRR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing facilities for long-term care. The PASRR process requires that all applicants to Medicaid-certified nursing facilities be given a preliminary assessment to determine whether they might have serious mental illness before admission. This is called a "PASRR Level I screen." Those individuals who test positive for PASRR Level I are then evaluated in-depth; this is called "PASRR Level II." The results of this evaluation result in a determination of need, a determination of an appropriate setting, and a set of recommendations for services for the individual's plan of care.

A review of the Pennsylvania Department of Human Services Office of Long-Term Living Bulletin entitled Revised Pennsylvania Preadmission Screening Resident Review (PASRR) Level 1 Identification Form (MA 376), effective July 1, 2024, revealed if the individual has a change in condition that affects program office criteria as found on the PASRR Level I form, a PASRR Level II evaluation form will need to be completed. Nursing facilities will communicate the need to have a PASRR Level II form done by notifying the department's Office of Long-Term Living, Division of Nursing Facility Field Operations Team.

Resident R10's clinical record revealed an admission date of 12/26/22 with diagnoses that included Multiple Sclerosis (MS is an autoimmune disease that affects the central nervous system resulting in a range of physical and cognitive symptoms), Dementia (loss of cognitive functioning affecting a person's memory and behaviors), and Depression (characterized by persistent feeling of sadness loss of interest in activities once enjoyed).

Resident R10's PASRR completed 12/21/22, under Section III Mental Health indicated that a Serious Mental Illness diagnosis may include Schizophrenia, Schizoaffective Disorder, Delusional Disorder, Psychotic Disorder, Personality Disorder, Panic or Other Severe Anxiety Disorder, Somatic Symptom Disorder, Bipolar Disorder, Depressive Disorder, or another mental disorder that may lead to chronic disability. Section III A for Diagnosis was checked as "No" with notation dated 12/27/22, that depression was managed with medication. The 12/21/22, PASRR was reviewed and signed off by Pennsylvania Department of Human Services Office Of Long Term Living on 4/11/23.

Resident R10's Minimum Data Set (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care) with an Assessment Reference Date (ARD) of 11/26/24, Section I5900 "Bipolar Disorder" was checked "Yes". Bipolar is defined as a mental health condition where you experience extreme mood swings that include emotional highs and lows. It causes significant shifts in mood, energy, activity levels, and concentration, affecting a person's overall functioning.

Resident R10's clinical record lacked evidence that the facility referred him/her for a PASRR level II through the state mental health authority following the new diagnosis of Bipolar on 11/26/25.

During an interview on 8/6/26, at 2:28 p.m. Registered Nurse Assessment Coordinator Office Manager Employee E7 confirmed that the facility did not refer to the state mental health authority following the new diagnosis of Bipolar as required.

28 Pa. Code 201.14(a) Responsibility of licensee

Plan of Correction - To be completed: 09/22/2026

The facility acknowledges the opportunity for improvement and submits this Plan of Correction as a credible allegation of compliance.
Corrective Action for Resident R10:
Resident R10's record was reviewed, and the appropriate PASRR Level II referral process was initiated based on the resident's diagnosis and change in condition.
Other Residents:
The Director of Resident Centered Services will conduct a 100% audit utilizing a generated report out of Point Click Care System, of current residents to identify any new diagnoses or changes in condition that may affect PASRR criteria. Any resident identified as requiring further review will be referred for a PASRR Level II evaluation as indicated.
Systemic Changes:
The facility revised its process to require the RNAC or designee to review new diagnoses and significant changes in condition for potential PASRR implications and initiate a Level II referral when required.
Education:
The RNAC, nursing leadership, Social Services, and applicable interdisciplinary team members will be educated by the Administrator or Designee on PASRR requirements, including identifying changes in condition or diagnoses requiring a Level II referral.
Monitoring:
The Director of Resident Centered Services or designee will audit applicable new diagnoses and significant changes in condition weekly for four weeks and monthly for three months utilizing a Point Click Care generated report. A level II PASSR will be completed if any qualifying diagnosis are found during these audits, and appropriate referrals will be made if warranted.
Results will be reported to the QAPI Committee. Any concerns identified will be addressed immediately.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.

Observations:

Based on review of facility policies, clinical records, observations, and staff interviews, it was determined that the facility failed to provide housekeeping services necessary to maintain clean bed linens for one of 27 residents reviewed (Resident R59).

Findings include:

Review of facility policy entitled "Bed Linen Policy" dated 1/5/26, indicated "Bed linen will be changed: At least weekly ... Whenever clinically indicated or requested by the resident.

Review of Resident R59's clinical record revealed an admission date of 4/21/26, with diagnoses that included hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones), and chronic diastolic heart failure (a condition where the heart cannot supply the body with enough blood).

Review of Resident R59's plan of care revealed a care plan dated 4/22/26 for impairment to skin with an intervention to keep bed linen clean.

Observations on 8/4/26, at 1:47 p.m. and again on 8/5/26, at 9:27 a.m. revealed Resident R59's pillowcase had several dry areas of a dark brown/red substance. His/her bed sheets had a gray hue (a color or shade of color) and appeared to be unclean.

During an interview on 8/4/26, at 1:47 p.m. with Resident R59, he/she said that they cannot remember the last time their sheets were changed.

During an interview on 8/5/26, at 2:29 p.m. the Director of Nursing (DON) confirmed that Resident R59's pillowcase had several areas of a dark brown/red substance on it and the sheets appeared unclean. The DON also confirmed that Resident R59's bed linens should have been changed.

28 Pa. Code 201.14 (a) Responsibility of Licensee

Plan of Correction - To be completed: 09/22/2026

The resident's (R59) bed linens were immediately changed, and the resident was provided with clean, fresh linens. The resident's room and bed were assessed to ensure the environment was clean, safe, comfortable, and homelike.
The Director of Nursing/RN Mangers conducted an audit of resident beds and rooms to identify any additional residents with soiled or inappropriate linens. No other concerns found.
Nursing will be re-educated by DON/RN Educator regarding facility expectations for maintaining clean and appropriate bed linens. Staff will be reminded that linens must be changed promptly when they are soiled, wet, stained, or otherwise unsuitable for resident use.
The Director of Nursing/designee will conduct random audits of 20 % of occupied resident beds and linens at least weekly for four weeks, then monthly for two months, to verify compliance. Any identified deficiency will be corrected immediately and staff will receive additional education or counseling as indicated.
Audit findings will be reviewed by the Administrator and/or Quality Assurance/Performance Improvement (QAPI) Committee. The monitoring process will continue until sustained compliance is demonstrated.

483.20(g)(h)(i)(j) REQUIREMENT Accuracy of Assessments:

Least serious deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident.

§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.

§483.20(h) Coordination. A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals.

§483.20(i) Certification.
§483.20(i)(1) A registered nurse must sign and certify that the assessment is completed.
§483.20(i)(2) Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment.

§483.20(j) Penalty for Falsification.
§483.20(j)(1) Under Medicare and Medicaid, an individual who willfully and knowingly-
(i) Certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or
(ii) Causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty or not more than $5,000 for each assessment.
§483.20(j)(2) Clinical disagreement does not constitute a material and false statement.

Observations:

Based on review of clinical records and Minimum Data Set (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care), and staff interview, it was determined that the facility failed to ensure that MDS assessments accurately reflected the status of one of 27 residents reviewed (Resident R11).

Findings include:

MDS instructions for section N "Medications," subsection N0350A "Insulin Injections Record the number of days that insulin injections were received during the last 7 days or since admission/entry or reentry if less than 7 days."

Resident R11's clinical record revealed an admission date of 2/11/24, with diagnoses that included Diabetes (a health condition caused by the body's inability to produce enough insulin), Dementia (loss of cognitive functioning affecting a person's memory and behaviors), and Congestive Heart Failure (CHF - a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply causing blood and fluids collect in your lungs and legs over time).

Resident R11's significant change MDS with an Assessment Reference Date (ARD a look back period of time for the MDS assessment) of 6/1/26, revealed section N0350 Insulin Injections "Record the number of days that insulin injections were received during the last 7 days or since admission/entry or reentry if less than 7 days" was coded as "0."

Resident R11's physician orders dated 4/23/26, revealed Lantus (a type of insulin to treat diabetes) 30 units subcutaneous (injection administered into the layer of fat between the skin and muscle) every bedtime. Resident R11's Medication Administration Record for May 2026 and June 2026 revealed Resident R11 received insulin injections six out of seven days.

During an interview on 8/6/2026, at 12:00 p.m. Registered Nurse Assessment Coordinator Office Manager Employee E7 confirmed that Resident R11's 6/1/26, significant change MDS section N0350 was coded incorrectly and should have been coded as "6."

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 211.5(f)(ix) Medical records

Plan of Correction - To be completed: 09/07/2026

I hereby acknowledge the CMS 2567-A, issued to ROUSE- WARREN COUNTY HOME for the survey ending 08/07/2026, AND attest that all deficiencies listed on the form will be corrected in a timely manner.

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