Rouse Warren County Home

In the surveyor’s words

From the most serious findings on record at Rouse Warren County Home, in the surveyor’s own words.

• Actual harm, isolatedF600Jun 25, 2026

  Based 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).Findings include: The Abuse, Neglect, and Exploitation policy, dated 1/5/26, revealed It is the policy of the Rouse Home to prevent, report, and investigate all allegations of abuse, neglect, or misappropriation of… […]

• Actual harm, isolatedF689Jun 25, 2026

  Based 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). […]

• Actual harm, isolatedF600Oct 20, 2023

  Based on review of facility policies, clinical records, and facility investigation, and staff interviews, it was determined that the facility failed to implement adequate safeguards in the locked dementia care unit to protect residents from abuse and physical altercation for two of 17 residents (Residents R25 and R94) resulting in actual harm of a laceration to the thumb and transport to the emergency room for treatment of sutures (stitches) for one Resident R94. Findings include: Review of the facility policy entitled, Staffing - [NAME] Lane dated 1/6/23, indicated that there will always be a minimum of two nursing staff on the hall when at least one resident is there. […]

• Actual harm, isolatedF689Oct 20, 2023

  Based on review of facility policies, clinical records, and facility documentation, and staff interviews, it was determined that the facility failed to provide a safe environment by not providing adequate supervision to protect residents from injury during a resident to resident altercation between two of 17 residents (Residents R25 and R94), that resulted in actual harm of a laceration to the thumb and transport to the emergency room for treatment of sutures (stitches) for one resident (Resident R94). Findings include: Review of the facility policy entitled, Staffing - [NAME] Lane dated 1/6/23, indicated that there will always be a minimum of two nursing staff on the hall when at least one resident is there. […]

• No harm, potential for more than minimal, patternF812Aug 7, 2026

  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. […]