Pennsylvania Department of Health
LAUREL SQUARE HEALTHCARE AND REHABILITATION CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

LAUREL SQUARE HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

There are 105 surveys for this facility. Please select a date to view the survey results.

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LAUREL SQUARE HEALTHCARE AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on an abbreviated survey in response to a three complaints, completed on November 6, 2025, it was determined that Laurel Square Healthcare and Rehabilitation Center, was not in compliance with the 28 Pa Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.

Plan of Correction:

483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan:

§483.21 Comprehensive Person-Centered Care Planning
§483.21(a) Baseline Care Plans
§483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

§483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

§483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.

Observations:

Based on review of clinical records, review of policy, and interview with staff, it was determined that facility did not develop and implement a baseline care plan for one out of six residents reviewed, related to bladder incontinence (Resident R2)

Findings include:
Review of facility policy ' Baseline Care Plans, ' revised March 2022, indicates that " a baseline plan of care to meet the resident ' s immediate health and safety needs is developed for each resident within forty-eight hours of admission. "
Review of Resident's R2 clinical record revealed the diagnoses of acute kidney failure with acute cortical necrosis, personal history of malignant neoplasm of prostate, obstructive and reflux uropathy, acute metabolic acidosis, artificial openings of urinary tract.
Review of Resident R2's ' skin and wound note completed on August 11, 2025, at 4:00 pm, stated Resident R2 was incontinent with following recommendations: " use appropriate moisture barrier creams per formulary to provide thorough skin care with each episode of incontinence. Use formulary briefs when indicated to manage moisture and assess often. While the patient is out of bed using a wheelchair, the use of a chair cushion is recommended."
Further review of ' skin and wound ' note stated that due to Resident R2's comorbidities, the resident had an increase risk of skin breakdown - " Recommend good hygiene and skin care to prevent skin breakdown. Recommend application of emollient daily. No open wounds on today's skin assessment; please keep patient's skin clean and dry, apply barrier cream as necessary to prevent skin breakdown, and avoid pressure on any bony prominence by adhering to turning protocols and floating heels as applicable. "
Further review of Resident R2's ' skin and wound ' progress notes dated August 11, 2025 at 10:49 am, states " new admission wound rounds conducted with in-house CRNP. The only recommendation is to have resident seen by podiatry for toes nails clipping. All other areas intact. "
Review of Resident R2's Braden scale for predicting pressure ulcer risk evaluation, completed on September 10, 2025, at 11:03 pm, indicated moderate risk.
Further review of Resident R2 ' s clinical record revealed that the resident was hospitalized on October 27, 2025 for surgery to sacral area due to osteomyelitis (infection of the bone).
Review of R2's care plan revealed no evidence of goals or interventions related to recommended preventative measure for bladder incontinence.

28 Pa. Code 211.10( c) Resident care policies
28 Pa. Code 211.12(d)(1) Nursing services

Plan of Correction - To be completed: 11/20/2025

0655 Base Line Care Plan
A. There is not opportunity to address the lack of a care plan post admission for the involved resident related to risk for skin breakdown.
B. Potentially all residents with risk for skin breakdown could be at risk if a care plan is not initiated following admission.
C. Education of the facility staff nurses has been conducted regarding the need to initiate a basic care plan within 48 hours post admission specific to identified risks/needs including any identified risk for skin breakdown.
D. The DON or designee will track education completion via attendance sheets to ensure 100% of the facility nurses have been educated. Education compliance will be reported to QAPI monthly for the next 3 months.

The DON or designee will conduct audits of basic care plans post admission to ensure initiation and inclusion of interventions for skin breakdown prevention if identified as at risk. The audits will be conducted daily x 2 weeks, if no identified issues, then weekly for 4 weeks, if no identified issues, then monthly for 3 months. The DON or designee will collect and monitor the audit results and report at the monthly QAPI meeting. The results of these reviews will be reported to QAPI for further recommendations as needed.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:

§483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(f). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

§483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

§483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

§483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

§483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

Observations:

Based on review of facility policy, review of clinical records, and interview with residents and staff, it was determined that the facility failed to provide pharmaceutical services to ensure accurate receiving, dispense and administration of medication to meet the needs of a resident according to professional standards of practice relating to medication administration for 1 of 11 residents reviewed (Resident R1)

Findings include:

Review of the facility's policy titled "Administering Medications" last revised April 2019 states that medications are administered in a safe and timely manner, and as prescribed.

Interview with Resident R1 on November 6, 2025, at 11:45 a.m. revealed that she had complained about her eye being red on October 22, 2025, and that the first time the eye drops were ordered they were lost by the overnight nurse, Employee E6. Then there was an issue getting the eye drops reordered due to a problem with the insurance not paying for the same prescription twice in one week. Resident R1 said that her eye got so bad that it was bright red and that she demanded to go to the emergency room (ER) to have it treated on November 2, 2025. She said that once she started using the eye drops from the hospital her eye was clearing up.

Review of Resident R1's clinical record the resident was admitted on February 3, 2025. An October 22, 2025, progress note revealed that Resident R1 complained of allergies and left eye redness, and that the physician was notified and ordered tobramycin eye drop (an antibiotic treatment used to combat bacterial infections of the eye) four times a day for five days.

Review of the electronic medication administration record (eMAR) reveals an October 22, 2025, physician order for tobramycin ophthalmic solution 0.3%, instill one drop in the left eye four times a day for left eye redness for five days starting on October 22, 2025. Further review of the eMAR revealed that each day from October 22, 2025, through November 3, 2025, has an open space, an X or a 9 (med not given see nurse note) all indicating that the resident did not receive the eye drops.

Review of the nursing progress notes from October 23, 2025, through October 27, 2025, indicate when a 9 was on the eMAR, a note was written to indicate that the eye drop medication was " on order " and documented as not given.

Interview on November 6, 2025, at 11:30 a.m. with Employee E3, floor nurse who has responsibility for Resident R1's medication administration revealed that there was a problem getting Resident R1's eye drops. That the eye drops were ordered on October 22, 2025, but did not come in until November 3, 2025, but that Resident R1 went to the ER (emergency room) on November 2, 2025, and got eye drops.

Interview on November 6, 2025, at 11:35 a.m. with Employee E4, unit manager confirmed that Resident R1's eye drops never came in, and that the resident went to the ER who gave her the same antibiotic eye drops. That Resident R1 saw the eye doctor on November 5, 2025, and another eye drop without the antibiotic were ordered but were still not in yet.

Interview with the Administrator on November 6, 2025, at 1:20 p.m. confirmed that there were issues getting Resident R1's eye drops and that after eleven days with no treatment the resident had to go to the ER to get the eye drops. The administrator was not satisfied with the way that the pharmacy handled this situation.

28 Pa Code 211.9 (a)Pharmacy Services

28 Pa. Code 211.12(d)(1) Nursing Services

Plan of Correction - To be completed: 11/20/2025

0755 Pharmacy Services
A. There is not opportunity to resolve the delay in medication receipt/administration for the involved resident.
B. Potentially all residents could be impacted by a delay in receipt of medications from pharmacy services.
C. Education has been conducted for all nursing staff on the steps to follow regarding any delay in medication receipt from pharmacy services including notification of physician, nursing supervisor, resident representative and pharmacy services.
D. The DON or designee will track education completion via attendance sheets to ensure 100% of the facility staff nurses have been educated on handling of medication delays. Education compliance will be reported to QAPI monthly for the next 3 months.

The DON or designee will conduct audits of any medication delays including follow up. The audits will be conducted daily x 2 weeks, if no identified issues, then weekly for 4 weeks, if no identified issues, then monthly for 3 months. The DON or designee will collect and monitor the audit results and report at the monthly QAPI meeting. The results of these reviews will be reported to QAPI for further recommendations as needed.

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