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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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

Initial comments:Name: - Component: -- - Tag: 0000
Based on an emergency preparedness survey completed on May 28, 2026, at Laurel Square Healthcare and Rehabilitation Center, there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000
Facility ID# 131302Component 01Based on a Revisit to a Medicare/Medicaid Recertification survey completed on May 28, 2026, it was determined that Laurel Square Healthcare and Rehabilitation Center was not in substantial compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).This is a three-story, Type II (000), unprotected, non-combustible building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:

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.

Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0923 Based on observation and interview, it was determined that the facility failed to maintain oxygen storage requirements, affecting two of three levels. Findings include: 1. Observation on May 28, 2026, revealed the following oxygen storage deficiencies: a. 11:10 a.m., 1-freestanding oxygen cylinder, on the second floor, the oxygen storage room. b. 11:50 a.m., on the second floor, the oxygen storage room door had a transfer grill. c. 11:55 a.m., on the third floor, the oxygen storage room door had a transfer grill. Exit Interview with the Administrator and Maintenance Director on May 28, 2026, at 12:00 p.m., confirmed the oxygen storage deficiencies. ************************************************** Based on an onsite revisit conducted on July 8, 2026, the following was determined: Items B and C were not completed. Exit interview with the Administrator and Maintenance Director on July 8, 2026, at 11:30 a.m. confirmed that items B and C were not completed.All other items associated with this tag have been completed.

Plan of Correction - To be completed: 07/14/2026

B. Maintenance Director will have
2nd Floor oxygen storage room door
replaced.
C. Maintenance Director will have
3rd Floor oxygen storage room door
replaced. Audits will be completed for 90
days by Maintenance Director. Findings
will be reported to QAPI and Safety
Committee for 90 days.

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