Mountain Laurel Healthcare and Rehabilitation CTR

In the surveyor’s words

From the most serious findings on record at Mountain Laurel Healthcare and Rehabilitation CTR, in the surveyor’s own words.

• Actual harm, isolatedF686Mar 19, 2026

  Based on review of facility policies, manufacturer's instructions, and clinical records, as well as resident and staff interviews, it was determined that the facility failed to provide necessary treatment and services for a Stage 3 pressure ulcer for one of nine residents reviewed (Resident 4), resulting in a deterioration of the wound; and failed to follow physician's orders in a timely manner for one of nine residents reviewed (Resident 3), which resulted in a delay of treatment.Findings include: The facility's wound care policy, dated March 19, 2026, indicated that to promote healing of wounds, it was the policy of the facility to have a physician's order for the procedure. […]

• Actual harm, isolatedF600Dec 1, 2023

  Based on review of facility policies, investigation reports, clinical records, and personnel files, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of six residents reviewed (Resident 2), resulting in harm to Resident 2 due to a fall that resulted in a fracture. Findings include: The facility's policy regarding abuse and neglect, dated October 24, 2023, indicated that the residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. […]

• Actual harm, isolatedF689Jan 4, 2023

  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 the resident environment remained as free of accident hazards as possible, by leaving a resident alone in the bathroom and failed to develop and implement new interventions for fall/injury prevention for one of six residents reviewed (Resident 2) who had a history of falls, which resulted in a fracture. Findings include: The facility's policy for assisting residents to the bathroom, dated September 27, 2022, indicated that when staff took the resident to the bathroom they were to provide the resident with as much privacy as possible and wait outside the door, if safety permitted, and ask the resident to signal when done. […]

• Actual harm, isolatedF604Oct 7, 2021

  Based on review of facility policies, residents' clinical records, and facility investigative reports, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from any physical restraints not required to treat the resident's medical symptoms for one of 42 residents reviewed (Resident 104), resulting in psychosocial harm to the resident, who was physically restrained by staff holding a sheet across her arms and placing socks on her hands, and in physical harm by locking the resident's wheelchair brakes to prevent movement, which resulted in a fall with injury that required a transfer to the hospital. […]

• No harm, potential for more than minimal, patternF565Jul 23, 2026

  Based on review of facility policy, Resident Council meeting minutes, as well as resident, staff interviews and observations, it was determined that the facility failed to make ongoing efforts to resolve grievances presented by the Resident Council.Findings include: A facility policy regarding resident and family grievances dated April 10, 2026, indicated that grievances may be voiced verbally during resident or family council meetings. The staff member receiving the grievance would record the nature and specifics of the grievance on the designated grievance form. The Grievance Official would take steps to resolve the grievance. […]