Pennsylvania Department of Health
LAUREL CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

LAUREL CENTER
Inspection Results For:

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

Initial comments:

Based on a State Licensure survey completed on October 22, 2025, it was determined that Laurel Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

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 clinical record review and observation, it was determined that the facility failed to follow physician orders for one of 24 sampled residents. (Resident 104)

Findings include:

Clinical record review revealed that Resident 104 was admitted to the facility on June 11, 2025, and had diagnoses that included chronic diastolic heart failure and atrial fibrillation (irregular heartbeat). On July 8, 2025, the physician ordered for staff to apply TED hose (anti embolism stockings) to Resident 104's right lower extremity (leg) in the morning and remove at bedtime. Review of the Minimum Data Set assessment dated September 18, 2025, revealed Resident 104 was dependent on staff for upper and lower body dressing. Multiple observations on October 19, 2025, between 12:00 p.m. and 2:27 p.m., and on October 20, 2025, between 9:20 a.m. and 2:00 p.m., revealed Resident 104 with no TED hose on his right lower extremity, per the physician's order.

28 Pa. Code 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 11/25/2025

1. Resident 104 Ted stocking was applied.

2. An initial audit will be completed by the Director of Nursing/Designee on current patients to verify ted stockings are in place per order.

3. CNE and or designee will re-educate Nursing staff staff on ted stocking application.

4. CNE and or designee will conduct random weekly audits x 4, then monthly x 2 of 5 residents with orders for TEDS to ensure TED stockings are applied.

Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:

§483.25(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Observations:

Based on facility policy review and clinical record review, it was determined that the facility failed to assess and document the status of wounds for one of 24 sampled residents. (Resident 104)

Findings include:

Review of the facility policy entitled, "Skin Integrity and Wound Management," last reviewed September 2025, revealed that the licensed nurse would complete a wound evaluation weekly.

Clinical record review revealed that Resident 104 was admitted to the facility on June 11, 2025, and had diagnoses that included chronic diastolic heart failure and atrial fibrillation (irregular heartbeat). Review of the Minimum Data Set assessment dated September 18, 2025, revealed Resident 104 was dependent on staff for upper and lower body dressing. Review of the care plan revealed Resident 104 had an unstageable pressure ulcer to the left forearm with an intervention for weekly skin checks to be completed the by licensed nurse. There was no documented evidence that a licensed nurse assessed or evaluated the wound per the policy since September 30, 2025.

28 Pa Code 211.12 (d)(1)(5) Nursing services.

Plan of Correction - To be completed: 11/25/2025

Resident 104 wound assessment documented.

An initial audit for the past 7 days will be completed by the Director of Nursing/Designee on current patients with wounds to ensure wound assessment has been completed

CNE and or designee will reeducate professional nursing staff on Wound Assessment policy and documentation.

CNE and or designee will conduct random weekly audits x4, then monthly x 2 of 5 residents with wounds to ensure wound assessment is completed and documented.

Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on a review of nursing time schedules, it was determined that the facility failed to meet the minimum nurse aide (NA) to resident ratios for one of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from September 30 through October 20, 2025, revealed the following:

The facility failed to meet the minimum NA to resident ratio of one NA for 15 residents on night shift (11:00 p.m. to 7:00 a.m.) on October 3, 2025.

Plan of Correction - To be completed: 11/25/2025

1.All residents received care in accordance with their plan of care and attending physician orders. The Clinical Leadership Team and scheduler review the schedule daily.
2 In the event of call offs the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff.
3The 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.
4 Nursing Supervisors have been educated on the Nursing Ratio requirements and the importance of maintaining the schedule as posted.
5 To monitor and maintain ongoing compliance the DON or designee will audit staffing weekly x4 weeks then monthly for two months.
6 Results will be taken to the QAPI for review X 3 months.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(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 a review of nursing time schedules, it was determined that the facility failed to meet the minimum licensed practical nurse (LPN) to resident ratios for two of 21 days reviewed.
Findings include:
Review of nursing schedules for 21 days from September 30 through October 20, 2025, revealed the following:
The facility failed to meet the minimum LPN to resident ratio of one LPN for 40 residents on night shift (11:00 p.m. to 7:00 a.m.) on October 12 and October 15, 2025.

§ 211.12(i)(2) LICENSURE Nursing services.:

(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 a review of nursing time schedules, it was determined that the facility failed to provide a minimum of 3.2 hours of direct care for each resident for one of 21 days reviewed.
Findings include:
Review of nursing schedules for 21 days from September 30 through October 20, 2025, revealed the following total nursing care hours below minimum requirements:
Friday, October 3, 2025: 3.16 care hours per resident.

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