Pennsylvania Department of Health
LAUREL VIEW VILLAGE
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 60 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


LAUREL VIEW VILLAGE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey, completed on May 21, 2026, it was determined that Laurel View Village was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.20(f)(5),483.70(h)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:

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.

§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

§483.70(h) Medical records.
§483.70(h)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

§483.70(h)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

§483.70(h)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

§483.70(h)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

§483.70(h)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.

Observations:

Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 24 residents reviewed (Resident 17).

Findings include:

A comprehensive MDS assessment for Resident 17, dated February 24, 2026, indicated that the resident was cognitively impaired, required assistance with daily care needs, received insulin, and had diagnoses that included diabetes.

Physician's orders for Resident 17, dated February 14, 2026, included an order for the resident to receive 11 units insulin aspart 100 units/milliliter (ml) at 7:00 a.m. daily if blood glucose is less than 80 mg/dL give 4 units, and if blood glucose is less than 70 mg/dL hold insulin recheck 1 hour after eating and administer insulin per sliding scale order.

Physician's orders for Resident 17, dated February 13, 2026, included an order for the resident to receive 9 units insulin aspart 100 units/ml at 11:00 a.m. daily if blood glucose is less than 80 mg/dL give 3 units, and if blood glucose is less than 70 mg/dL hold insulin recheck 1 hour after eating and administer insulin per sliding scale order.

Physician's orders for Resident 17, dated February 13, 2026, included an order for the resident to receive 13 units insulin aspart 100 units/ml at 4:00 p.m. daily if blood glucose is less than 80 mg/dL give 5 units and if blood glucose is less than 70 mg/dL hold insulin recheck 1 hour after eating and administer insulin per sliding scale order.

Review of Resident 17's Medication Administration Record (MAR) for February 2026, March 2026, April 2026, and May 2026 revealed no documented evidence of how many units received per physician's orders at the above times.

Interview with the Director of Nursing on May 20, 2026, at 11:02 a.m. confirmed that there was no documented evidence in Resident 17's clinical record of how many units the resident received daily at the above times.

28 Pa Code 211.5(f) Clinical Records.

28 Pa. Code 211.12(d)(5) Nursing Services.

Plan of Correction - To be completed: 07/13/2026

The remedy for resident 17 was completed by updating the orders for insulin to a sliding scale order format in Point Click Care to allow documentation of varying doses administered based on the physician order and retrieval of that information on the Medication Administration Record (MAR). The process for which was followed did not support deficient practice however a potential to capture more accurate unit administration. Nursing was confirming they were following the order; however the documentation lacked the ability to confirm specific manual entry of units.

A review of all other resident's insulin orders was completed.

The Medication Administration policy was updated to include that all insulin orders where the amount administered is based on the result of the blood glucose will be entered as a sliding scale order. All current Healthcare licensed nursing staff were assigned the policy to acknowledge in Policy Stat (Laurel View Village's online policy review platform). All newly hired staff as well as temporary (agency) staff are to be educated that the sliding-scale order is to be used when there is a choice of the amount of insulin to be administered.

The Director of Nursing, Assistant Director of Nursing, Healthcare Nursing Leadership, or designee will conduct audits for staff compliance with insulin order documentation 2 times weekly for 4 weeks, then weekly for 4 weeks, then every other week for one month.

On-the-spot education will be provided to staff as needed. The results of these logs/audits along with a Root Cause Analysis of any identified issues will be brought to the Quality Assurance and Performance Improvement Committee for two quarters for further analysis and corrective action as needed. The committee will determine the need for additional audits or reporting.

483.10(e)(1),483.12(a)(2),483.45(c)(3)(d)(e) REQUIREMENT Right to be Free from Chemical Restraints:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.

§483.10(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

§483.10(e)(1) The right to be free from any . . . chemical restraints
imposed for purposes of discipline or convenience, and not required to treat the
resident's medical symptoms, consistent with §483.12(a)(2).

§483.12
The resident has the right to be free from abuse, neglect, misappropriation of
resident property, and exploitation as defined in this subpart. This includes but is
not limited to freedom from corporal punishment, involuntary seclusion and any
physical or chemical restraint not required to treat the resident's medical
symptoms.
§483.12(a) The facility must-. . .
§483.12(a)(2) Ensure that the resident is free from . . . chemical restraints
imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms.
. . . .
§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic.

§483.45(d) Unnecessary drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-
(1) In excessive dose (including duplicate drug therapy); or
(2) For excessive duration; or
(3) Without adequate monitoring; or
(4) Without adequate indications for its use; or
(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or
(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.

§483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that--

§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

§483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

§483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

§483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Observations: Based on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to ensure a resident's medication regimen was free from unnecessary psychotropic medications and that non-pharmacological interventions were implemented prior to initiation of an antipsychotic medication for one of 24 residents reviewed (Resident 10) for unnecessary medications. Findings included: The facility's policy regarding psychotropic medications (any medication that affects brain activities associated with mental processes and behavior), dated October 15, indicated that psychotropic medications are not used unless clinically indicated, are prescribed at the lowest effective dose, and are subject to gradual dose reduction and behavioral interventions in accordance with federal regulations and informed consent will be obtained per state law. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 10, dated April 8, revealed that the resident is cognitively impaired, requires assistance with daily care needs and has medical diagnoses that includes anxiety, depression, and Post Traumatic Stress Disorder (PTSD). Physician orders for Resident 10 dated March 21, 2026, included orders for the resident to receive 1 milligram of lorazepam (an antianxiety medication) every 12 hours as needed. A review of the Medication Administration Record (MAR) for Resident 10 revealed that she received 1mg lorazepam on April 5, 2026, at 12:00 a.m. and on April 7,2026, at 4:15 a.m. A review of the clinical record for Resident 10 revealed that there was no non-pharmacological interventions attempted prior to the medication administration. During an interview with the Director of Nursing on May 21, 2026, at 9:35 a.m. confirmed that there were no non-pharmacological interventions attempted prior to the as needed medication and there should have been. 28 Pa. Code 211.12(d)(5) Nursing Services.

Plan of Correction - To be completed: 07/13/2026

Remedy could not be immediate as the event occurred in the past.

A review of the orders for all current residents in house with Anxiety Medication was completed to ensure that the behaviors documentation was attached to all PRN (as needed/requested) orders

The Medication Administration policy was updated to include requiring non-pharmacological interventions to be attempted prior to administration of an as needed psychotropic medication with documentation to occur in the Electronic Medical Record. All current Healthcare licensed nursing staff were assigned the policy to acknowledge in Policy Stat (Laurel View Village's online policy review platform). All newly hired staff as well as temporary (agency) staff are to be educated that documentation of non-pharmacological interventions and documentation of those interventions must occur. The Behavioral Intervention Monitoring for Psychotropic Medications policy was updated to include certified nursing assistants documenting behaviors witnessed and non-pharmacological interventions attempted in the EMR.

All current Healthcare Licensed and unlicensed nursing staff were assigned the policy to acknowledge in Policy Stat. All newly hired staff as well as temporary (agency) staff are to be educated that non-pharmacological interventions must be attempted and documented.

The Director of Nursing, Assistant Director of Nursing, Healthcare Nursing Leadership, or designee will conduct audits for staff compliance with documentation of non-pharmacological intervention documentation 3 times weekly for 4 weeks, then weekly for 4 weeks, then every other week for one month.
On-the-spot education will be provided to staff as needed. The results of these logs/audits along with a Root Cause Analysis of any identified issues will be brought to the Quality Assurance and Performance Improvement Committee for two quarters for further analysis and corrective action as needed. The committee will determine the need for additional audits or reporting.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.

Observations: Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to develop and implement an individualized care plan for one of 24 residents reviewed (Resident 5). Findings include: A Quarterly Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated April 16, 2026, revealed that the resident was cognitively impaired, was sometimes understood and could sometimes understand others, and required assistance from staff with daily care needs. A physician's order for Resident 5, dated November 28, 2025, included orders for the resident to maintain a 1500cc fluid restriction. A physician's order for Resident 5 dated January 21, 2026, revealed that the resident's humidifier was no longer to be filled with distilled water due to the resident drinking the water. A nursing note for Resident 5 dated, January 22, 2026, revealed that the resident has been attempting to get water where she can in bathrooms and was observed drinking the water from her humidifier. A nursing note for Resident 5 dated, January 27, 2026, revealed that the resident has been non-compliant with her fluid restrictions. She was observed taking medicine cups from the med cart and filling them up with water from the bathroom. There was no documented evidence that a care plan was developed to address Resident 5's non-compliance with fluid restrictions. Interview with the Nursing Home Administrator on May 20, 2026, at 9:25 a.m. confirmed that Resident 5 did not have care plans developed to address her non-compliance with fluid restrictions. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(5) Nursing services.

Plan of Correction - To be completed: 07/13/2026

Prior to the survey team leaving the facility, Resident 5's non-compliant care plan was updated to include non-compliance with the fluid restriction.

All other residents care plans were reviewed for non-compliance where appropriate.

All progress notes and behaviors documented in the Point of Care section of the Electronic Medical Record Point Click Care will be reviewed 5 days a week for non-compliant behavior. These will be discussed and reviewed during morning stand up meeting with the interdisciplinary team. Care plans will be updated as needed for non-compliance. Care plans reviewed during grand rounds , Laurel Views Weekly Resident Room and Medical Record Review Program, as well as during quarterly care plans.

Education to be completed with all licensed and unlicensed Healthcare Staff as well as Healthcare Leadership staff.
All current Healthcare staff, licensed and unlicensed nursing staff were assigned the Grand Rounds policy to acknowledge in Policy Stat (Laurel View Village's online policy review platform). All newly hired staff as well as temporary (agency) staff are to be educated on the documentation of a resident's non-compliance with orders.
Director of Nursing, Healthcare Nursing Leadership, or designee will conduct audits for appropriate care plans for non-compliance with care orders 2 times weekly for 4 weeks, then weekly for 4 weeks, then every other week for one month.

On-the-spot education will be provided to staff as needed. The results of these logs/audits along with a Root Cause Analysis of any identified issues will be brought to the Quality Assurance and Performance Improvement Committee for two quarters for further analysis and corrective action as needed. The committee will determine the need for additional audits or reporting.

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards:

§483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.

Plan of Correction - To be completed: 07/13/2026

The remedy for resident 8 could not be immediate as the event occurred in the past. Registered Nurse Supervisor Progress noted relating to the change of condition was not missing, however within the progress note, there was not identifiable wording that the Registered Nurse who was completing the progress note was the Registered Nurse which was assessing the resident and lacking the wording to reference the previously imputed progress notes for the change in condition. Documentation was present but lacked specifics as noted above.

Audit was completed of recent residents which fell into category of Change of status to include the documentation that the Registered Nurse which was completing the progress note was in the fact the nurse who completed the assessment and vital signs to correlate.

Education to be completed to all current Registered Nursing Supervisors regarding documentation of assessments for changes in condition. Resident Change in Condition policy updated to include documentation of assessment of body system affected and set of vital signs to be documented. Education to be completed by all current Healthcare licensed and unlicensed staff and Life Enrichment staff regarding notifying the Registered Nursing Supervisor when a change in condition is noted.

All current Registered Nursing Staff were assigned the Resident Change in Condition Policy to acknowledge in Policy Stat (Laurel View Village's online policy review platform). All Healthcare staff, licensed and unlicensed, were assigned the Obtaining and Reporting Resident Vital Signs policy in Policy Stat. All newly hired staff as well as temporary (agency) staff are to be educated on the documentation of assessment with vital signs for changes in condition.
The Director of Nursing, Assistant Director of Nursing, Healthcare Nursing Leadership, or designee will conduct audits for nursing assessments with changes in condition 2 times weekly for 4 weeks, then weekly for 4 weeks, then every other week for one month.

On-the-spot education will be provided to staff as needed. The results of these logs/audits along with a Root Cause Analysis of any identified issues will be brought to the Quality Assurance and Performance Improvement Committee for two quarters for further analysis and corrective action as needed. The committee will determine the need for additional audits or reporting.

483.25 REQUIREMENT Quality of Care:

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations: Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders regarding medication administration were followed for two of 24 residents reviewed (Residents 17, and 33). Findings include: A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) dated February 24, 2026, for Resident 17 revealed that the resident was cognitively impaired, was rarely understood and rarely understood others, required assistance from staff for daily care needs, received insulin and had a diagnosis of diabetes. Physician's orders for Resident 17, dated February 14, 2026, included an order for the resident to receive Novolog flexpen insulin aspart 100unit/milliliter and Inject 11 units subcutaneously at 7:00 a.m. and if blood glucose is <80 mg/dL inject 8 units and if blood sugar <70 mg/dL to hold insulin and obtain another blood glucose in 1 hour after meals and to administer per sliding scale order. Review of Resident 17's Medication Administration Record (MAR) for April 2026, revealed that on April 22 during the 7:00 a.m. medication pass the blood glucose level was 71mg/dL and that 11 units of Novolog flexpen insulin aspart 100 unit/milliliter was administered. Physician's orders for Resident 17, dated February 13, 2026, included an order for the resident to receive Novolog flexpen insulin aspart 100 unit/milliliter and Inject 13 units subcutaneously at 4:00 p.m. and if blood glucose is <80 mg/dL to inject 5 units of Novolog flexpen insulin aspart and if blood glucose is <70 mg/dL to hold insulin and obtain another blood glucose in 1 hour after meals and to administer per sliding scale order. Review of Resident 17's MAR for April 2026, revealed that on April 22 at 4:00 p.m. the resident's blood glucose level was 78 mg/dL and that 13 units of Novolog flexpen insulin aspart was injected. Interview with Director of Nursing on May 20, 2026, at 9:22 a.m. confirmed that on the above dates and times the wrong dose of insulin was administered to Resident 17. A comprehensive MDS assessment dated May 18, 2026, for Resident 33 revealed that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included high blood pressure. Physician's order for Resident 33, dated July 9, 2024 revealed the resident was to receive 5 milligrams (mg) of lisinopril (a medication to treat high blood pressure) once a day and to hold the medication if the resident' systolic blood pressure (top number of blood pressure) is <100 mmHg or if the heart rate is < 60 beats per min (bpm). A review of the MAR for Resident 33 for April 2026 revealed that on April 26, 2026, the resident's blood pressure was 98/66 mmHg and they received 5mg lisinopril. Interview with the Director of Nursing on May 20, 2026, at 1:06 p.m. confirmed that the resident received 5mg lisinopril on the above date and time and shouldn't have. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Plan of Correction - To be completed: 07/13/2026

Insulin Documentation – Resident 17
The corrective action for Resident 17 was completed by updating the insulin order in PointClickCare (Electronic Medical Record) to a sliding scale order format. This change allows documentation of varying doses administered based on the physician's order rather than documenting only that the order was followed. The process for which was followed did not support deficient practice however a potential to capture more accurate unit administration. Nursing was confirming they were following the order; however the documentation lacked the ability to confirm specific manual entry of units.

A review of all other residents' insulin orders was completed to identify any residents who may have been affected by the same deficient practice. Any insulin order requiring varying doses based upon blood glucose results was entered in PointClickCare using the sliding scale order format.

The Medication Administration Policy was revised to specify that all insulin orders in which the amount administered is determined by the blood glucose result must be entered as a sliding scale order.

All currently employed Healthcare licensed nursing staff were assigned the revised policy for review and acknowledgment through PolicyStat, Laurel View Village's online policy management and review platform. In addition, all newly hired staff and temporary agency staff will receive education regarding the requirement to utilize the sliding scale order format whenever there is a range of insulin doses available based on blood glucose results.
The Director of Nursing, Assistant Director of Nursing, Healthcare Nursing Leadership, or designee will conduct audits for staff compliance with insulin order documentation two times weekly for four weeks, then weekly for four weeks, and then every other week for one month.

On-the-spot education will be provided to staff as needed. The results of these audits, along with a Root Cause Analysis of any identified issues, will be presented to the Quality Assurance and Performance Improvement Committee for two quarters for additional analysis and corrective action, as needed. The committee will determine whether further audits or reporting are warranted.

Blood Pressure Documentation – Resident 33
Physician orders for Resident 33 dated July 9, 2024, directed administration of 5 milligrams of lisinopril once daily and instructed staff to hold the medication if the resident's systolic blood pressure (top number of the blood pressure reading) was less than 100 millimeters of mercury or if the resident's heart rate was less than 60 beats per minute. Review of the Medication Administration Record for April 2026 revealed that on April 26, 2026, Resident 33's blood pressure was 98/66 millimeters of mercury and the resident received 5 milligrams of lisinopril.

Because the event occurred in the past, an immediate remedy for Resident 33 was not possible.
Residents with medications that include blood pressure or pulse parameters have the potential to be affected by the same deficient practice. Staff will review and follow physician orders requiring blood pressure and pulse parameters prior to medication administration.

The Medication Administration Policy was revised to emphasize the importance of verifying blood pressure parameters before administering medications.

All currently employed Healthcare licensed nursing staff were assigned the revised policy for review and acknowledgment through PolicyStat, Laurel View Village's online policy management and review platform. All newly hired staff and temporary agency staff will receive education regarding the importance of following blood pressure parameters prior to medication administration.

The Director of Nursing, Assistant Director of Nursing, Healthcare Nursing Leadership, or designee will conduct audits for staff compliance with following blood pressure parameters when administering medications two times weekly for four weeks, then weekly for four weeks, and then every other week for one month.

On-the-spot education will be provided to staff as needed. The results of these audits, along with a Root Cause Analysis of any identified issues, will be presented to the Quality Assurance and Performance Improvement Committee for two quarters for additional analysis and corrective action, as needed. The committee will determine whether additional audits or reporting are

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility:

§483.25(c) Mobility.
§483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

§483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

§483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.

Observations:

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that interventions were in place as ordered for two of 24 residents reviewed, a left palm guard to reduce contractures and pain and prevent skin breakdown (Resident 4) and a left hand towel roll to prevent contractures (Resident 33).

Findings include:

The facility's policy regarding splints and braces dated October 1, 2025, indicated that the purpose was to prevent or reduce contractures, maintain proper joint alignment, reduce pain and/or promote skin integrity.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated April 3, 2026, indicated that the resident was moderately cognitively impaired, dependent on staff for care, had diagnoses that included a stroke which resulted in a decrease in hand muscle function and an increase in weakness of the left arm/hand.

Resident 4's care plan, dated October 1, 2025, indicated that the resident had impaired left side mobility and a potential for decline in skin integrity related to his stroke. Physician's orders, dated November 17, 2025, included an order for the resident to have a palm guard in place in the left hand during the day.
Observations on May 18, 2026, at 10:40 a.m., 1:18 p.m. and 2:45 p.m., and May 19, 2026, at 9:29 a.m. and 11:05 a.m. revealed that Resident 4 did not have a left palm guard in place as ordered.

Interview with Registered Nurse 1 on May 19, 2026, at 11:22 a.m. indicated that if the left palm guard is ordered to be in place and documented as such, then it should be in place on the resident's left hand.
Interview with Nurse Aide 2 on May 19, 2026, at 12:20 p.m. indicated that she was unaware that Resident 4 was ordered or had a left palm guard.

Interview with Physical Therapy Assistant 3 on May 19, 2026, at 3:35 p.m. indicated that one of the purposes of the left palm guard was to provide comfort to the resident.

A comprehensive MDS assessment for Resident 33, dated May 18, 2026, indicated that the resident was moderately cognitively intact, dependent on staff for care, had diagnoses that included hemiparesis resulted in a decrease in hand muscle function and an increase in weakness of the left arm/hand.

Resident 33's care plan, dated May 20, 2025, indicated that the resident had left hand contractures and hemiparesis and required a left handroll to be utilized as ordered.

Physician's orders for Resident 33 dated May 19, 2025, included an order for the resident to utilize a handroll in her left hand during the day for contracture management.

Observations on May 18, 2026, at 10:00 a.m., 1:18 p.m. and 2:45 p.m., and May 20, 2026, at 9:01 a.m., 10:05 a.m., and 11:35 a.m., 12:03 p.m. and 1:15 p.m. revealed that Resident 33 did not have a left handroll in place as ordered.

Interview with Nurse Aide 4 on May 20, 2026, at 1:15 p.m. indicated that the resident did not have her left handroll in and it should be utilized.

Interview with the Director of Nursing on May 20, 2026, at 1:37 p.m. confirmed that Resident 4's left palm guard and Resident 33's left hand towel roll, were to be in place as per physician order, and they were not, and that there was no documented evidence that the residents refused the interventions.

42 CFR 483.25(c)(1)-(3) Increase/Prevent Decrease in Range of Motion/Mobility.

28 Pa. Code 211.12(d)(5) Nursing services.

Plan of Correction - To be completed: 07/13/2026

Resident 4
An immediate review of the resident 4's care plan and care guides was completed. The palm roll had been removed from the care guide prior and the care plan without the physician's order being discontinued. To immediately correct, the resident palm guard was placed into the resident's left hand. The resident admitted that he frequently removes the palm roll and does not utilize it during the day, but staff does offer it to him. The care plan and care guides were updated. A non-compliance with palm roll care plan was added to the resident.

All other residents with Palm Guard orders were reviewed for accuracy of documentation, order and implementation with no errors found.

Resident with Adaptive Equipment will be discussed and reviewed during morning meeting with the interdisciplinary team. Care plans will be updated as needed for non-compliance. Care plans reviewed during grand rounds, Laurel Views Weekly Resident Room and Medical Record Review Program, as well as during quarterly care plans.

All current Healthcare staff which within their job duties allows for assistance with this equipment, licensed and unlicensed nursing staff were assigned the Grand Rounds policy and the Sprint/Brace Policy to acknowledge in Policy Stat (Laurel View Village's online policy review platform). All newly hired staff as well as temporary (agency) staff are to be educated on the documentation of a resident's non-compliance with orders.

The Director of Nursing, Assistant Director of Nursing, Healthcare Nursing Leadership, or designee will conduct audits for compliance with splint/braces in place 2 times weekly for 4 weeks, then weekly for 4 weeks, then every other week for one month.

On-the-spot education will be provided to staff as needed. The results of these logs/audits along with a Root Cause Analysis of any identified issues will be brought to the Quality Assurance and Performance Improvement Committee for two quarters for further analysis and corrective action as needed. The committee will determine the need for additional audits or reporting.

Resident 33

An immediate review of resident 33's care plan and care guides was completed. The resident frequently removes her left handroll herself. A non-compliance with handroll care plan was implemented.
These will be discussed and reviewed during morning meeting with the interdisciplinary team. Care plans will be updated as needed for non-compliance. Care plans reviewed during grand rounds, Laurel Views Weekly Resident Room and Medical Record Review Program, as well as during quarterly care plans.

All current Healthcare staff, which within their job duties allows for assistance with this equipment, licensed and unlicensed nursing staff were assigned the Grand Rounds policy and the Sprint/Brace Policy to acknowledge in Policy Stat (Laurel View Village's online policy review platform). All newly hired staff as well as temporary (agency) staff are to be educated on the documentation of a resident's non-compliance with orders.

The Director of Nursing, Assistant Director of Nursing, Healthcare Nursing Leadership, or designee will conduct audits for compliance with splint/braces in place 2 times weekly for 4 weeks, then weekly for 4 weeks, then every other week for one month.

On-the-spot education will be provided to staff as needed. The results of these logs/audits along with a Root Cause Analysis of any identified issues will be brought to the Quality Assurance and Performance Improvement Committee for two quarters for further analysis and corrective action as needed. The committee will determine the need for additional audits or reporting.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Observations:

Based on observations, and staff interviews, it was determined that the facility failed to provide a separately locked, permanently affixed compartment in the refrigerator for the storage of controlled drugs (medications with the potential to be abused) in one of two medication rooms reviewed.

Findings include:

Observations in the facility's main medication room on May 20, 2026, at 10:12 a.m. revealed one small, refrigerator containing one bottle of liquid Ativan (a controlled medication used to treat anxiety). The liquid Ativan was not in a secured, permanently affixed locked compartment. The locked compartment was affixed to the shelf, but the shelf was easily removed from the refrigerator.

Interview with Registered Nurse 5 at the time of the observation confirmed that the shelf containing the locked container was removable from the refrigerator.

Interview with the Nursing Home Administrator on May 20, 2026, at 2:54 p.m. confirmed the bottle of liquid Ativan was not in a permanently affixed compartment and should have been.

28 Pa. Code 211.9(a)(1) Pharmacy Services.

Plan of Correction - To be completed: 07/13/2026

Upon immediate Investigation, Root Cause Identified that when the Nursing Refrigerator was replaced Environmental Services did not replace the security hooks which were on the previous medication/narcotic refrigerator Prior to the survey team leaving the facility, the narcotic box and shelf were permanently affixed to the wall of the medication refrigerator. Root Cause Identified that when the Nursing Refrigerator was replaced Environmental Services did not replace the security hooks which were on the previous medication/narcotic refrigerator.

The temperature log for medication refrigerators containing vaccinations was updated to include checking that narcotic boxes are permanently affixed in the refrigerator, to be checked twice daily. The Medication Storage and Labeling policy was updated on Policy Stat to include checking the narcotic boxes and with a copy of the new temperature log.

All current Healthcare licensed nursing staff were assigned the policy to acknowledge in Policy Stat (Laurel View Village's online policy review platform). All newly hired staff as well as temporary (agency) staff are to be educated on the use of the new temperature log.

Environmental Services staff were reeducated on the importance of replacing all security and protection measures on all equipment that is being replaced. Director of Nursing, Administrator or Designee is to verify upon completion of task that Environmental Services completed replacement correctly.
The Director of Nursing, Assistant Director of Nursing, Healthcare Nursing Leadership, or designee will conduct audits for staff compliance with checking that the narcotic box is permanently affixed 2 times weekly for 4 weeks, then weekly for 4 weeks, then every other week for one month.

On-the-spot education will be provided to staff as needed. The results of these logs/audits along with a Root Cause Analysis of any identified issues will be brought to the Quality Assurance and Performance Improvement Committee for two quarters for further analysis and corrective action as needed. The committee will determine the need for additional audits or reporting.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement