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

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MOUNTAIN LAUREL HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

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MOUNTAIN LAUREL HEALTHCARE AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a revisit survey completed on November 12, 2025, it was determined that Mountain Laurel Healthcare and Rehabilitation Center corrected all the federal deficiencies cited during the survey of August 14, 2025, under the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities; however, the facility was not in compliance with the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:


Based on review of nursing schedules, review of staffing information furnished by the facility, and staff interview, it was determined that the facility failed to provide a minimum of one licensed practical nurse (LPN) per 30 residents on the evening shift for one of five days reviewed for September 25, 2025, through September 29, 2025.

Findings include:

Review of facility census data revealed:

On September 25, 2025, the facility's census was 99 during the evening shift, which required 3.30 LPN ' s on the evening shift. Review of the nursing time schedules revealed that 3.23 LPN ' s provided care during the evening shift.

However, there were no additional excess higher-level staff were available to compensate for these deficiencies.

Interview with the Nursing Home Administrator on November 12, 2025, at 9:05 a.m. confirmed that the facility did not meet the required LPN-to-resident staffing ratios for the days listed above.




 Plan of Correction - To be completed: 01/07/2026

1. All residents received care in accordance with their plan of care and attending physician orders.

2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. Facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff.

3. Facility nursing staff have been educated on the 7/1/2024 Nursing Ratios and Patient Per Day requirements and the importance of maintaining the schedule as posted.

4. To monitor and maintain ongoing compliance the Director Of Nursing or designee will audit staffing weekly x4 weeks then monthly for two months.
Results will be taken to the Quality Assurance & Performance Imporvement for review and revision as needed.

§ 211.12(i)(2) LICENSURE Nursing services.:State only Deficiency.
(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:


Based on review of nursing schedules and staff interviews, it was determined that the facility failed to provide 3.20 hours of direct resident care for each resident for five of five days (24-hour periods) reviewed for September 25, 2025, through September 29, 2025.

Findings include:

Review of the nursing time schedules provided by the facility revealed that the facility provided 2.83 hours of direct care for each resident on September 25; 3.13 hours of direct care for each resident on September 26; 3.08 hours of direct care for each resident on September 27; 2.96 hours of direct care for each resident on September 28; and 3.04 hours of direct care for each resident on September 29.

Interview with the Nursing Home Administrator on November 12, 2025, at 9:05 a.m. confirmed that the facility did not meet the required daily hours of direct resident care for each resident on the days listed above.



 Plan of Correction - To be completed: 01/07/2026

1. All residents received care in accordance with their plan of care and attending physician orders.

2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. Facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff.

3. Facility nursing staff have been educated on the 7/1/2024 Nursing Ratios and Patient Per Day requirements and the importance of maintaining the schedule as posted.

4. To monitor and maintain ongoing compliance the Director Of Nursing or designee will audit staffing weekly x4 weeks then monthly for two months.
Results will be taken to the Quality Assurance & Performance Imporvement for review and revision as needed.

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