Laurel Center
LAUREL CENTER in HAMBURG, PA — inspection on January 29, 2026.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
jeopardy to resident health or safety
and five sampled family members to identify any potential allegations of sexual misconduct four times per week, then two times per month.
Any identified concerns will result in an immediate, thorough investigation.
The Market Operations Advisor educated the Clinical Lead on the expectations for review of completed audits four times per week, then two times per month.The Director of Nursing (DON) or designee will conduct interviews of five sampled staff members to identify any potential allegations of sexual misconduct four times per week, then two times per month.
Any identified concerns will result in an immediate thorough investigation.
The Market Operations Advisor educated the Clinical Lead on the expectations for review of completed audits four times per week, then two times per month The alleged perpetrator was suspended and will continue to be suspended until the investigation is completed.
The facility will follow appropriate protocol per policy and legal requirements. If the alleged perpetrator returns to work, he will be re-educated on the abuse policy and have random weekly observations of resident care 12 times.
The results of the audits will be presented at the QAPI meetings for the review.
The survey team validated that the Immediate Jeopardy was removed on January 29, 2026, at 9:30 p.m., after review of the facility training documentation, interviews, and review of facility policies and procedures following the facility's implementation of the corrective action plan for the Immediate Jeopardy. 28 Pa.
Code 201.14(a) Responsibility of licensee 28 Pa.
Code 201.18(b)(1)(2)(3)(e)(1) Management 28 Pa Code 201.29(a) Resident Rights 28 Pa Code 211.12(d)(1)(5) Nursing services
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
01/29/2026
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurel Center
125 Holly Road Hamburg, PA 19526
SUMMARY STATEMENT OF DEFICIENCIES
Based on clinical record review, review of facility documentation, and resident interview, it was determined that the facility failed to assess triggers and develop and implement an individualized person-centered plan to render trauma informed care for a resident who was at risk for re-traumatization resulting in psychosocial harm for one resident. (Resident 1)Findings include: Clinical record review revealed that Resident 1 had diagnoses that included muscle weakness.
Review of the Minimum Data Set assessment (MDS, a periodic evaluation of resident care needs) dated January 5, 2026, revealed that the resident was interviewable and did not have cognitive impairment.
Review of the care plan revealed that the resident was dependent on staff for activities of daily living (ADLs), which included personal hygiene.
Review of facility documentation revealed that on January 21, 2026, the resident reported that on the evening shift of January 20, 2026, nurse aide (NA) 1 washed her in a circular motion during incontinence care and stated, Do you like that? twice and flicked his tongue at her.
The resident yelled at him to not say anything like that again.
Review of facility documentation dated January 21, 2026, revealed that NA 2 wrote a statement which indicated that on January 21, 2026, at 6:30 a.m., Resident 1 reported that during evening care the previous night, January 20, 2026, NA 1 cleaned her perineal area in a circular motion and asked if she liked that.
When the resident asked him to repeat himself to ensure she understood, he stated, Do you like that? a second time and flicked his tongue at her. In an interview on January 29, 2026, at 11:30 a.m., the resident reported that during incontinence care, NA 1 rubbed her vagina, in the area where the labia begin, with balled up cleansing wipes in a circular motion. NA 1 then asked, Do you like that? When the resident responded with, What? NA 1, stated, Do you like it? Resident 1 reported that NA 1 was continually flicking his tongue and his eyes were in a fixed stare.
The resident reported that she felt NA 1 was trying to get a reaction out of her by rubbing her in that way.
The resident reported that she yelled twice to NA 1, Don't you ever say anything like that to me again! The resident reported she was trying to think of a way to call for help.
The resident reported that she was horrified inside, the vision of NA 1 during the encounter will stick with her, she felt that everything she had done in life and her record was ruined, she was scared, she felt that she had been singled out, and she was upset that her family had to read about the incident. Resident 1 was tearful multiple times during this interview. Resident 1 stated that she was not informed of any new interventions, options for interventions or updates to her care plan in the facility until January 28, 2026, seven days after the initial allegation.
The resident was not aware of any measures that were implemented to protect her, following the allegation. In a confidential interview on January 29, 2026, at 2:59 p.m., a visitor of Resident 1's reported that the resident had been negatively impacted psychosocially by the alleged incident that was reported on January 21, 2026.
Although clinical record review revealed that on January 22, 2026, social services spoke with the resident regarding inappropriate comments made by a staff member, there was a lack of evidence that the facility conducted a thorough assessment to identify the resident's trauma associated with the physical and verbal aspects of the allegation of sexual abuse to identify triggers and prevent re-traumatization.
There was a lack of evidence that the facility discussed any new interventions, options for additional interventions, or updates to the care plan with Resident 1 until January 28, 2026.
There was a lack of evidence that the facility implemented new, person-centered, interventions to render trauma informed care until January 29, 2026. 28 Pa.
Code 211.12(d)(3)(5) Nursing services
Facility ID: