Laurelbrooke Personal Care.

“Direct care staff A and B were suspended pending investigation of an allegation of abuse but were returned to work before the Department's investigation concluded, rather than remaining suspended until DHS made a final determination.”

“Direct care staff person A does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry as required.”

“Direct care staff B received only 2 hours of training during the January 2025 to December 2025 training year, falling short of the required minimum of 12 hours of annual training relating to job duties.”

“Direct care staff B did not receive training during the January 2025 to December 2025 training year in the following required topics: medication self-administration, instruction on meeting resident needs through the DME/RASP, infection control, personal care service needs of the resident, and safe management techniques.”

“Direct care staff B did not receive training during the January 2025 to December 2025 training year in the following required topics: fire safety, emergency preparedness procedures, and falls and accident prevention.”

“A resident's assessment and support plan does not address diagnoses that were documented in the resident's annual medical evaluation.”

“Resident #2's medical evaluation did not include a list of medications, and Resident #3's evaluation was missing medical professional information.”

“Resident #1's assessment did not address hallucinations indicated on physician orders, failing to reflect significant changes in resident condition.”

“Residents lack privacy for telephone calls, as they can only use landline phones in the kitchen and medication rooms.”

“From 10 PM on 10/10/25 to 6 AM on 10/11/25, 34 residents were present in the home with no staff certified in first aid or CPR.”

“The first aid kit is missing required items including disposable gloves, gauze pads, thermometer, adhesive tape, scissors, and tweezers.”

“An unsealed bag of hotdogs was found in the walk-in refrigerator, violating requirements that leftover food be labeled and dated.”

“Approximately 1/2 inch thick accumulation of lint was found in the lint traps of the 2nd and 3rd commercial dryers, creating a fire hazard.”

“Resident #2's medical evaluation did not include documentation of the need for the resident to be in a secured dementia care unit.”

“Resident #2's support plan does not address the need for secured dementia care unit placement or the resident's behavior of eating unauthorized food from the refrigerator and need for two-person assist.”

“Resident who required assistance with toileting, transfers, and ambulating did not receive this assistance during overnight hours (10:00 pm to 6:45 am). Resident was found on the floor next to bed in a puddle of urine with soaked nightgown, brief, blanket, and bedding. This was a repeat violation.”

“Support plan for a resident receiving hospice services did not address the hospice services provided to the resident and how this need will be met. This was a repeat violation.”

“Two residents were admitted to the home without completed preadmission screening forms documenting that the facility could meet the residents' needs.”

“An agent of the Department requested access to resident demographic information, which was not provided until 4:00 p.m., approximately 6.5 hours after the initial request around 9:30 a.m.”

“The home failed to provide adequate assistance with medications for a resident who began refusing prescribed medications in November 2024. The resident was hospitalized for a urinary tract infection, refused medication treatment, and was readmitted to the hospital, yet the home did not update the resident's assessment and support plan or provide appropriate care for this medication refusal need.”

“The home failed to re-assess a resident and provide timely medical evaluation and care when the resident began exhibiting frequent agitated and aggressive behaviors and refusing prescribed medications from November through December 2024, resulting in hospitalizations.”

“The home failed to assist a resident in securing timely medical care and failed to update the resident's assessment and support plan when the resident's health status declined with repeated medication refusals, leading to hospital admissions for urinary tract infection in November and December 2024.”

“A resident's Medication Administration Record indicated multiple medication refusals in November and December 2024, but the home failed to notify the prescriber of these refusals as required within 24 hours.”

“The home failed to update a resident's assessment and support plan when the resident's condition significantly changed in November 2024, with the resident beginning to exhibit agitated and aggressive behaviors and refusing prescribed medications.”

“Direct care staff person A did not receive training in safe management techniques during the training year. This is a repeat violation.”

“Staff person A did not receive training in Older Adults Protective Services Act during the training year. This is a repeat violation.”

“An electric portable space heater was in use in the administrator's office at 2:00 pm. Portable space heaters are prohibited.”

“A resident's most recent medical evaluation was not completed within the required annual timeframe.”

“A resident's medication administration record (MAR) for September 2024 does not include the initials of the staff person who administered medication at 8:00 pm on the specified date. The information required by regulation was not recorded at the time of medication administration. This is a repeat violation.”

“A resident prescribed multiple medications including items on a sliding scale three times daily, and other medications twice daily was not administered these medications or levels checked on specified dates during specific time periods. The home failed to follow the prescriber's orders. This is a repeat violation.”

“An assessment was not completed for a resident within 15 days of admission to the home.”

“A resident's assessment was not completed in accordance with the requirement for additional assessments to be performed annually.”

“Direct care staff A received only 3 hours of training during the January 2023 through December 2023 training year, but required minimum is 12 hours of annual training relating to job duties.”

“Direct care staff A did not receive training in required topics including medication self-administration, instruction on meeting resident needs (DME & RASP), care for residents with dementia and cognitive impairment, infection control/cleanliness/immobility concerns, personal care service needs, and safe management techniques during the January 2023 through December 2023 training year.”

“Direct care staff A did not receive required annual training in the following areas: Older Adult Protective Services Act, resident's rights, and emergency preparedness during the January 2023 through December 2023 training year.”

“Medication labeling deficiencies were identified: Resident #1's medication label indicated incorrect dosing instructions (take one tab by mouth 4 times daily instead of correct instructions), and Resident #7's insulin medication label was not attached to or inside the plastic bag containing the insulin pen. This is a repeat violation from 12/7/22.”

“Resident #1's black Glucometer was not calibrated to the correct date and time, indicating a failure to implement proper procedures for safe storage, access, security, distribution and use of medications and medical equipment.”

“The home did not have a system to safeguard resident laundry from being lost or misplaced. Residents' clean clothing was not consistently returned within 24 hours after laundering.”

“A resident in the Secure Dementia Care Unit suffered an unwitnessed fall with a head injury (approximately 4-inch forehead cut with bleeding). Staff did not take appropriate action to secure immediate medical treatment, and the home only contacted the designated person who declined hospitalization without obtaining proper medical evaluation.”

“A resident refused scheduled doses of prescribed medication on multiple dates and times. The home did not report these refusals to the prescriber within 24 hours as required.”

“The home did not follow prescriber's orders for insulin administration. Insulin doses were withheld on multiple dates and times because staff believed resident's levels were low or resident did not eat, acting outside prescriber's directions.”

“Following the Activities Director's resignation in mid-October 2023, the home offered only one activity once per week to residents in the Secure Dementia Care Unit, failing to meet the requirement for multiple types of activities offered at least weekly.”

“The home failed to complete and submit an Act 13 form to the Area Agency on Aging within 48 hours for an allegation of abuse against staff person B involving resident #1. Additionally, an allegation of abuse involving staff person B and resident #2 was not reported to the Area Agency on Aging or documented with an Act 13 form within the required timeframe.”

“The home did not immediately develop and implement a plan of supervision or suspend staff person B following an allegation of abuse involving resident #1. Staff person B continued to provide direct care to multiple residents in the secured dementia care unit without an approved plan of supervision.”

“The home failed to report an allegation of abuse involving staff person B and resident #2 to the Department's personal care home regional office or complaint hotline within 24 hours.”

“A direct care staff person (staff person B) was observed physically grabbing and forcefully 'ripping' resident #2's hand away from a hallway railing before assisting the resident back into a wheelchair, failing to treat the resident with dignity and respect.”