Rouse Warren County Home

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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). 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. [...]

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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.)

Inspectors wroteBased on review of facility policy, review of facility documentation and clinical records, and staff interviews, it was determined that the facility failed to ensure that one resident was free of neglect during care which resulted in actual harm of an acute non-displaced fracture of the lateral malleolus and medial malleolus ( a recent break located on the outer side of the ankle at the end of the fibula and the inner side of the ankle at the end of the tibia with the bone fragments not shifting out of their normal position) for one of four residents reviewed (Resident R1).

Inspectors wroteBased on review of facility policy, review of facility documentation and clinical records, observations, and staff interviews, it was determined that the facility failed to provide necessary precautionary measures to maintain resident safety and prevent injury during transport in a wheelchair and/or Broda chair (a specialized chair used for residents who require pressure relief, advanced postural support, and long-term sitting) resulting in actual harm of an acute non-displaced fracture of the lateral malleolus and medial malleolus ( a recent break located on the outer side of the ankle at the end of the fibula and the inner side of the ankle at the end of the tibia with the bone fragments not shifting out of their normal position) for one of four residents reviewed (Resident R1).

Inspectors wroteBased 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).

Inspectors wroteBased on review of a facility policy, observations and staff interviews, it was determined that the facility failed to safely store food containers in the main kitchen and ensure that food was stored in accordance with standards for food safety in pantry refrigerators on two of three nursing units observed (100 Unit and 700 Unit).

Inspectors wroteBased on review of facility policy, observations and staff interviews, it was determined that the facility failed to appropriately discard outdated medications for one of three medication carts reviewed (700 cart).

Inspectors wroteBased on review of facility policies and grievances, observations, and staff interviews, it was determined that the facility failed to maintain a clean and sanitary environment on two of seven units observed (100 and 200 units).

Inspectors wroteBased on review of facility policy and clinical records, and staff interview it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day) upon transfer for three of 24 residents reviewed (Residents R30, R88 and R114).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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).