Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rouse Warren County Home during CMS and state inspections, most recent first.
Three residents with respiratory or cardiac conditions were found with improperly maintained respiratory care equipment, including overdue or undated oxygen tubing, dirty concentrator filters, and a nebulizer mask left in a room after the order was discontinued. Staff interviews confirmed that required cleaning and labeling protocols were not followed.
Surveyors identified improper storage of food containers in the main kitchen, where metal steam table trays were stacked while wet, and found multiple unlabeled food items in unit pantry refrigerators. Staff confirmed that food items lacked required resident names and dates, and that wet stacking of trays occurred, contrary to facility policy.
A medication cart was found to contain an open NovoLog FlexPen that had been in use beyond the 28-day limit specified by both facility policy and manufacturer guidelines. An LPN confirmed during observation that the insulin pen was expired and should have been discarded.
The facility did not maintain a clean and sanitary environment on two units, as required by policy. Grievances and direct observations revealed unclean resident rooms and common areas, with visible debris, spills, and unemptied trash. Multiple staff expressed concerns about housekeeping, and the administrator confirmed the unsanitary conditions.
The facility did not meet the required NA staffing ratios during a day shift, with only 11.50 NAs available for 125 residents, falling short of the mandated 12.50 NAs. This was confirmed by the Nursing Home Administrator.
The facility failed to provide written notice of its bed-hold policy to residents or their representatives upon transfer to a hospital. This deficiency was identified for three residents, who were transferred without receiving the required notice, as confirmed by the Nursing Home Administrator.
The facility failed to ensure accurate MDS assessments for three residents. One resident was incorrectly documented as having a tracheostomy, while two others were wrongly marked with a psychotic disorder. These errors were confirmed by the RN Assessment Coordinator.
A facility did not provide a written summary of the baseline care plan and order summary to a resident with dementia, hypertension, and hypothyroidism within 48 hours of admission, as required by their policy. The RNAC was supposed to review and deliver the care plan, but the clinical record lacked evidence of this action, confirmed by the DON.
A facility failed to reconcile pre-discharge medications with post-discharge medications in a resident's discharge summary. The facility's policy requires listing discharge medications, including name, dose, directions, and quantity, but this was not done for a resident with dementia, high blood pressure, depression, anxiety, and weakness. Nursing documentation also lacked details on medications sent home. The DON confirmed the absence of required documentation.
The facility did not ensure medications were dated when opened and discarded in a timely manner. During an observation, two opened vials of Tubersol in the central medication storage room were found without an open date, preventing staff from determining the discard date. An LPN confirmed the absence of open dates on the vials.
The facility failed to maintain accurate clinical records for two residents. One resident's record incorrectly included a PTSD diagnosis without confirmation from a licensed practitioner, while another resident's record contained pre-admission information for a different potential resident. These discrepancies were confirmed by the DON and Director of Social Services, violating Pennsylvania Code regulations.
Failure to Maintain and Clean Respiratory Care Equipment
Penalty
Summary
The facility failed to maintain respiratory care equipment in accordance with its own policy and physician orders for three residents. Facility policy required that humidifier bottles, oxygen tubing, and concentrator filters be changed or cleaned every two weeks and labeled with the date of change. For one resident with a discontinued nebulizer order, a nebulizer machine and mask remained in the room, with the mask found on the floor, which was confirmed by the Director of Nursing as inappropriate. Another resident receiving supplemental oxygen had a tubing bag and humidifier bottle that were not changed as required, undated oxygen tubing, and an external concentrator filter covered with a significant amount of white fluffy substance. An LPN confirmed these items were overdue for maintenance and cleaning. A third resident, also on supplemental oxygen, was observed to have an external concentrator filter covered with a copious amount of white fluffy substance, and an LPN confirmed the filter needed cleaning. All three residents had significant respiratory or cardiac diagnoses, including respiratory failure, heart failure, COPD, and emphysema. The observations and staff interviews confirmed that the facility did not follow its own protocols for respiratory equipment maintenance, labeling, and cleanliness, as required by physician orders and facility policy.
Improper Food Storage and Labeling in Kitchen and Unit Pantries
Penalty
Summary
The facility failed to ensure proper storage and handling of food in accordance with professional standards and its own policies. Observations in the main kitchen revealed that metal steam table trays were stacked while still wet, with clear liquid and moist food particles found between the trays. Staff interviews confirmed that trays were not allowed to air dry as required by policy, and that wet stacking had occurred on multiple occasions. The Dietary Manager and a Dietary Aide both acknowledged the improper practice and the need for the trays to be rewashed and dried properly. Additionally, inspections of pantry refrigerators on two nursing units found multiple food items that were not labeled with resident names or dates, as required by facility policy. Items included unknown foods wrapped in foil, salads, sandwiches, and containers with unidentifiable contents, all lacking proper labeling. Staff interviews confirmed that these items were not compliant with labeling requirements. The DON confirmed that there is a designated refrigerator for family-brought food, and that unit pantry refrigerators are intended only for dietary staff use during mealtimes.
Failure to Discard Expired Insulin on Medication Cart
Penalty
Summary
The facility failed to appropriately discard an outdated medication on one of three medication carts reviewed. According to facility policy, RNs and LPNs are required to check expiration dates and dispose of expired medications, with insulin specifically to be discarded 28 days after opening, regardless of the manufacturer’s expiration date. During an observation of the Unit 700 medication cart, an open NovoLog FlexPen was found with an open date that exceeded the 28-day limit. At the time of observation, an LPN confirmed that the insulin pen was beyond the allowed usage period and should have been discarded. This finding was based on review of facility policy, manufacturer guidelines, and staff interview.
Failure to Maintain Clean and Sanitary Environment on Multiple Units
Penalty
Summary
The facility failed to maintain a clean and sanitary environment on two of seven units observed, specifically the 100 and 200 units. Facility policies required daily room cleaning and room completes, including pulling and replacing garbage bags, sweeping, and mopping floors. However, review of grievances revealed concerns about the cleanliness of a resident room and bathroom on the 200 unit. Observations showed thick dry spots from spilled liquid, debris, straw wrappers, napkins, fuzzy dust, food crumbs, and unemptied trash in a resident room and the 200-unit break/storage area. Staff interviews across all units indicated widespread concerns about housekeeping, particularly on the 100, 200, and 300 units. The Nursing Home Administrator confirmed the dirty conditions during a tour.
Nurse Aide Staffing Ratio Not Met
Penalty
Summary
The facility failed to meet the required nurse aide (NA) staffing ratios during the day shift on December 7, 2024. Specifically, the regulation mandates a minimum of one NA per 10 residents during the day. On the day in question, the facility had a census of 125 residents, necessitating 12.50 NAs, but only 11.50 NAs were on duty. This staffing shortage was confirmed by the Nursing Home Administrator during an interview on December 17, 2024.
Plan Of Correction
It is the policy of the Rouse Home to provide adequate staffing to meet the needs of all residents. Following the new staffing requirements issued July 1, 2024, the Rouse Home has implemented numerous new measures to assure that we are doing all that we can to meet the new nurse staffing requirements. Staffing is reviewed by the Nursing Home Administrator and Director of Nursing, and or designee daily. If the staffing schedule does not meet the ratio minimums, we put incentives out to all of the nursing staff via On-shift message, personal phone calls, and text messages, and incentives are offered for staff to pick up these shifts. Additionally, we have made changes to our time and attendance policy in efforts to minimize staff calling off their scheduled shift. In 2024, we held a total of two NA classes which has helped to increase the overall number of CNAs employed at the Rouse Home. We have significantly increased our recruitment efforts as well in 2024. Efforts include job postings on Indeed, Rouse website, Facebook, radio ads in various counties, and welcome walk-in interviews at any time. Our HR team attends job fairs and other local events to advertise open positions. We also market available opportunities at our local high schools as well as colleges and universities in Warren County and the surrounding areas. We market sign-on bonuses for new hires and also offer our current staff recruitment bonuses for referring anyone to the open nursing positions, and increased our 2nd and 3rd shift differentials as part of our recruitment and retention efforts. Going forward, the projected monthly schedule will be reviewed with the roll out of the schedule to identify any shifts that do not meet ratio. Once we identify these shifts, we will begin to proactively recruit to fill the open shift. Administrator, DON, Nurse Scheduler will audit daily staffing including CNA ratios, along with all steps taken to fill vacancies 5 days a week and ongoing. Results of the audits will be reviewed and recorded in the monthly QAPI meetings.
Failure to Provide Bed-Hold Policy Notice
Penalty
Summary
The facility failed to provide written notice of its bed-hold policy to residents or their representatives upon transfer to a hospital or during therapeutic leave. This deficiency was identified for three residents during a review of facility policy, clinical records, and staff interviews. The facility's policy, dated January 6, 2024, requires the Admissions office to send out a Notice of Involuntary Discharge, Transfer, and Bed Hold letter at the time of transfer. However, documentation was lacking for Residents R30, R88, and R114, indicating that they or their representatives did not receive the required notice. Resident R30, who was admitted with chronic obstructive pulmonary disease, vascular dementia, and hypotension, was transferred to the hospital on May 31, 2024, without receiving the bed-hold policy notice. Similarly, Resident R88, with diagnoses including dementia, anxiety, hyperlipidemia, and feeding difficulties, was transferred on August 16, 2024, without the notice. Resident R114, diagnosed with dementia, difficulty walking, hyperlipidemia, and anxiety, was transferred on September 2, 2024, also without receiving the notice. The Nursing Home Administrator confirmed the absence of documentation and acknowledged that the policy should have been provided upon transfer.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) accurately reflected the status of three residents. For Resident R78, the MDS inaccurately indicated that the resident had a tracheostomy, which was not supported by visual observation or the resident's confirmation. This discrepancy was noted in the quarterly MDS assessment with an Assessment Reference Date (ARD) of 6/10/24. Additionally, the MDS assessments for Residents R72 and R99 incorrectly marked psychotic disorder as an active diagnosis. Resident R72's comprehensive MDS with an ARD of 7/01/24 and Resident R99's quarterly MDS with an ARD of 7/29/24 both contained this error. The Registered Nurse Assessment Coordinator confirmed these inaccuracies during interviews conducted on 9/26/24 and 9/27/24.
Failure to Provide Baseline Care Plan to Resident
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan and order summary to a resident and/or their representative within 48 hours of admission, as required by their policy. The policy, dated 1/06/24, mandates that the RNAC reviews the 48-hour care plan for completion and provides a copy to the resident or family in the resident's room, documenting this in the record. However, for Resident R55, who was admitted with diagnoses including dementia, hypertension, and hypothyroidism, there was no evidence in the clinical record that this requirement was fulfilled. The Director of Nursing confirmed the absence of documentation for providing the care plan and order summary to the resident or their representative upon admission.
Failure to Reconcile Discharge Medications
Penalty
Summary
The facility failed to include a reconciliation of all pre-discharge medications with the resident's post-discharge medications in the discharge summary for one of the two closed records reviewed. The facility's policy, dated 1/06/24, requires that discharge medications be listed in the Discharge Planning & Instructions assessment section, including the name of the medication, dose, directions for use, and quantity. However, the clinical record of Resident CR122, who had diagnoses including dementia, high blood pressure, depression, anxiety, and weakness, lacked evidence of medication reconciliation at the time of discharge. Additionally, nursing documentation did not provide details on the type or number of medications sent home with the resident. The Director of Nursing confirmed the absence of this documentation and acknowledged that discharge medications should have been reconciled and documented in the discharge summary.
Failure to Date and Discard Medications Properly
Penalty
Summary
The facility failed to ensure that medications were properly dated when opened and discarded in a timely manner in the central medication storage room. A review of the facility's policy on Medication Administration General Guidelines, dated 1/06/24, indicated that new multi-dose bottles must be dated and initialed upon opening. Additionally, the manufacturer's guidelines for Tubersol PPD, a solution used for tuberculosis testing, require that vials in use for 30 days should be discarded. During an observation of the drug storage area, two opened vials of Tubersol were found without an open date, making it impossible for staff to determine the appropriate discard date. This was confirmed by an LPN, who acknowledged the lack of open dates on the vials.
Inaccurate Clinical Records for Two Residents
Penalty
Summary
The facility failed to maintain accurate clinical records for two residents, leading to deficiencies in safeguarding resident-identifiable information and maintaining medical records according to professional standards. For one resident, identified as R48, the clinical record included a diagnosis of Post Traumatic Stress Disorder (PTSD) that was added on a specific date. However, subsequent psychiatric consult notes did not provide evidence of this diagnosis being confirmed by a licensed practitioner. This discrepancy was acknowledged by the Director of Nursing during an interview. Another resident, identified as R116, had their clinical record erroneously contain pre-admission information from a referring agency intended for another potential resident. This error was confirmed by the Director of Social Services during an interview. The facility's failure to accurately maintain these clinical records was in violation of specific Pennsylvania Code regulations related to nursing services and medical records.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Youngsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Warren Manor | 6.3 mi | ★★★★★ | 5 | 0 |
| Kinzua Nursing And Rehab | 8 mi | ★★★★★ | 8 | 1 |
| Heritage Park Rehab & Skilled Nursing | 17.3 mi | ★★★★★ | 1 | 0 |
| Corry Manor | 19.2 mi | ★★★★★ | 20 | 0 |
| Heritage Green Rehab & Skilled Nursing | 19.3 mi | ★★★★★ | 18 | 0 |
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