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Health Inspection Summary
Laurel Lakes Rehabilitation and Wellness Center
201 Franklin Farm Lane
Chambersburg, PA 17201
(717) 264-2715
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Deficiency Category
Inspection Date:
8/22/24
Complaint Reporting Period:
4/1/24 - 3/31/25
Inspection Date:
9/21/23
Complaint Reporting Period:
4/1/23 - 3/31/24
Inspection Date:
10/6/22
Complaint Reporting Period:
4/1/22 - 3/31/23
Freedom from Abuse, Neglect, and Exploitation Deficiencies010
Quality of Life and Care Deficiencies459
Infection Control Deficiencies112
Resident Assessment and Care Planning Deficiencies644
Nursing and Physician Services Deficiencies004
Resident Rights Deficiencies246
Nutrition and Dietary Deficiencies112
Pharmacy Service Deficiencies232
Environmental Deficiencies000
Administration Deficiencies000

Detailed result for inspection on 8/22/24
Date of last standard health inspection:8/22/24Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25
Date(s) of infection control inspection(s) between 4/1/24 - 3/31/25
No infection control inspections
Total number of Health Deficiencies for this nursing home:16
Average number of Health Deficiencies in Pennsylvania:10.3
Average number of Health Deficiencies in the United States:9.6
Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide enough food/fluids to maintain a resident's health.

8/22/2410/2/24
2 - Minimal harm or potential for actual harm
Few

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

4/2/244/23/24
2 - Minimal harm or potential for actual harm
Few

Provide routine and 24-hour emergency dental care for each resident.

4/2/244/23/24
2 - Minimal harm or potential for actual harm
Some

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

10/18/2411/1/24
4 - Immediate jeopardy to resident health or safety
Some
Infection Control Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide and implement an infection prevention and control program.

8/22/2410/2/24
2 - Minimal harm or potential for actual harm
Some
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

8/22/2410/2/24
2 - Minimal harm or potential for actual harm
Some

Assess the resident when there is a significant change in condition

4/2/244/23/24
2 - Minimal harm or potential for actual harm
Few

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

7/29/248/20/24
2 - Minimal harm or potential for actual harm
Few

Assess the resident when there is a significant change in condition

8/22/2410/2/24
2 - Minimal harm or potential for actual harm
Few

Ensure services provided by the nursing facility meet professional standards of quality.

8/22/2410/2/24
2 - Minimal harm or potential for actual harm
Some

Ensure each resident receives an accurate assessment.

8/22/2410/2/24
2 - Minimal harm or potential for actual harm
Some
Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.
Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Reasonably accommodate the needs and preferences of each resident.

8/22/2410/2/24
2 - Minimal harm or potential for actual harm
Few

Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

10/18/2411/1/24
2 - Minimal harm or potential for actual harm
Few
Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

8/22/2410/2/24
2 - Minimal harm or potential for actual harm
Some
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

4/2/244/23/24
2 - Minimal harm or potential for actual harm
Few

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

8/22/2410/2/24
2 - Minimal harm or potential for actual harm
Some
Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.
Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 9/21/23
Date of last standard health inspection:9/21/23Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24
Date(s) of infection control inspection(s) between 4/1/23 - 3/31/24
No infection control inspections
Total number of Health Deficiencies for this nursing home:19
Average number of Health Deficiencies in Pennsylvania:10.3
Average number of Health Deficiencies in the United States:9.4
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

9/21/2311/1/23
2 - Minimal harm or potential for actual harm
Few
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

9/21/2311/1/23
2 - Minimal harm or potential for actual harm
Few

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

7/14/237/11/23
4 - Immediate jeopardy to resident health or safety
Few

Provide care and assistance to perform activities of daily living for any resident who is unable.

9/21/2311/1/23
2 - Minimal harm or potential for actual harm
Few

Assist a resident in gaining access to vision and hearing services.

9/21/2311/1/23
2 - Minimal harm or potential for actual harm
Few

Provide safe, appropriate dialysis care/services for a resident who requires such services.

4/20/235/16/23
2 - Minimal harm or potential for actual harm
Some
Infection Control Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide and implement an infection prevention and control program.

12/27/231/11/24
2 - Minimal harm or potential for actual harm
Some
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

6/13/236/21/23
2 - Minimal harm or potential for actual harm
Few

Ensure services provided by the nursing facility meet professional standards of quality.

9/21/2311/1/23
2 - Minimal harm or potential for actual harm
Few

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

9/21/2311/1/23
2 - Minimal harm or potential for actual harm
Few

Ensure each resident receives an accurate assessment.

9/21/2311/1/23
2 - Minimal harm or potential for actual harm
Few
Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.
Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

9/21/2311/1/23
2 - Minimal harm or potential for actual harm
Few

Reasonably accommodate the needs and preferences of each resident.

9/21/2311/1/23
2 - Minimal harm or potential for actual harm
Few

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

9/21/2311/1/23
2 - Minimal harm or potential for actual harm
Few

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

9/21/2311/1/23
1 - Potential for minimal harm
Some
Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

9/21/2311/1/23
2 - Minimal harm or potential for actual harm
Some
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

9/21/2311/1/23
2 - Minimal harm or potential for actual harm
Few

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

9/21/2311/1/23
2 - Minimal harm or potential for actual harm
Some

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

9/21/2311/1/23
2 - Minimal harm or potential for actual harm
Some
Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.
Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 10/6/22
Date of last standard health inspection:10/6/22Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23
Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23
Total number of Health Deficiencies for this nursing home:29
Average number of Health Deficiencies in Pennsylvania:9.6
Average number of Health Deficiencies in the United States:8.7
Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

10/6/2211/22/22
2 - Minimal harm or potential for actual harm
Some

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

12/13/221/10/23
2 - Minimal harm or potential for actual harm
Some

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

7/22/228/23/22
2 - Minimal harm or potential for actual harm
Few

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

10/6/2211/22/22
2 - Minimal harm or potential for actual harm
Some

Provide enough food/fluids to maintain a resident's health.

10/6/2211/22/22
2 - Minimal harm or potential for actual harm
Some

Provide safe and appropriate respiratory care for a resident when needed.

7/26/228/23/22
2 - Minimal harm or potential for actual harm
Some

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

10/6/2211/22/22
2 - Minimal harm or potential for actual harm
Some

Provide safe and appropriate respiratory care for a resident when needed.

10/6/2211/22/22
2 - Minimal harm or potential for actual harm
Few

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

1/30/232/28/23
2 - Minimal harm or potential for actual harm
Some
Infection Control Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

10/6/2211/22/22
2 - Minimal harm or potential for actual harm
Few

Provide and implement an infection prevention and control program.

10/6/2211/22/22
2 - Minimal harm or potential for actual harm
Few
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

7/26/228/23/22
2 - Minimal harm or potential for actual harm
Some

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

10/6/2211/22/22
2 - Minimal harm or potential for actual harm
Some

Ensure each resident receives an accurate assessment.

10/6/2211/22/22
2 - Minimal harm or potential for actual harm
Few

Ensure services provided by the nursing facility meet professional standards of quality.

10/6/2211/22/22
2 - Minimal harm or potential for actual harm
Few
Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

10/6/2211/22/22
2 - Minimal harm or potential for actual harm
Some

Observe each nurse aide's job performance and give regular training.

10/6/2211/22/22
2 - Minimal harm or potential for actual harm
Some

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

10/6/2211/22/22
2 - Minimal harm or potential for actual harm
Few

Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

10/6/2211/22/22
2 - Minimal harm or potential for actual harm
Some
Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Reasonably accommodate the needs and preferences of each resident.

10/6/2211/22/22
2 - Minimal harm or potential for actual harm
Few

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

10/6/2211/22/22
2 - Minimal harm or potential for actual harm
Some

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

10/6/2211/22/22
2 - Minimal harm or potential for actual harm
Some

Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.

10/6/2211/22/22
2 - Minimal harm or potential for actual harm
Some

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

10/6/2211/22/22
2 - Minimal harm or potential for actual harm
Some

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

1/30/232/28/23
2 - Minimal harm or potential for actual harm
Some
Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

10/6/2211/22/22
2 - Minimal harm or potential for actual harm
Few

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

7/14/227/27/22
3 - Actual harm
Few
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

10/6/2211/22/22
2 - Minimal harm or potential for actual harm
Some

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

10/6/2211/22/22
2 - Minimal harm or potential for actual harm
Some
Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.
Administration Deficiencies
No Administration Deficiencies were found during this inspection period.
Complaints and facility-reported incidents in the past 3 years
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

4/2/244/23/24
2 - Minimal harm or potential for actual harm
Few

Provide routine and 24-hour emergency dental care for each resident.

4/2/244/23/24
2 - Minimal harm or potential for actual harm
Some

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

10/18/2411/1/24
4 - Immediate jeopardy to resident health or safety
Some

Assess the resident when there is a significant change in condition

4/2/244/23/24
2 - Minimal harm or potential for actual harm
Few

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

7/29/248/20/24
2 - Minimal harm or potential for actual harm
Few

Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

10/18/2411/1/24
2 - Minimal harm or potential for actual harm
Few

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

4/2/244/23/24
2 - Minimal harm or potential for actual harm
Few

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

7/14/237/11/23
4 - Immediate jeopardy to resident health or safety
Few

Provide safe, appropriate dialysis care/services for a resident who requires such services.

4/20/235/16/23
2 - Minimal harm or potential for actual harm
Some

Provide and implement an infection prevention and control program.

12/27/231/11/24
2 - Minimal harm or potential for actual harm
Some

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

6/13/236/21/23
2 - Minimal harm or potential for actual harm
Few

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

12/13/221/10/23
2 - Minimal harm or potential for actual harm
Some

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

7/22/228/23/22
2 - Minimal harm or potential for actual harm
Few

Provide safe and appropriate respiratory care for a resident when needed.

7/26/228/23/22
2 - Minimal harm or potential for actual harm
Some

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

1/30/232/28/23
2 - Minimal harm or potential for actual harm
Some

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

7/26/228/23/22
2 - Minimal harm or potential for actual harm
Some

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

1/30/232/28/23
2 - Minimal harm or potential for actual harm
Some

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

7/14/227/27/22
3 - Actual harm
Few
Infection control inspection deficiencies in the past 3 years
This nursing home has not been cited for any deficiencies on infection control inspections in the last 3 years.
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