Health inspection·December 27, 2023

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program to prevent the transmission of Coronavirus Disease 2019 (COVID-19) for one of 3 residents reviewed (Resident 1). Residents Affected - Some Findings Include: Review of the facility policy titled, COVID-19 Infection Control Protocols to Minimize Exposure, with an annual review in 2023, For residents going to medical appointments, regular communication between the medical facility and the nursing home (in both directions) is essential to help identify residents with potential exposures or symptoms of COVID-19 before they enter the facility so that proper precautions can be implemented. Review of the closed clinical record on December 26, 2023, revealed Resident 1 with diagnoses that included end stage renal disease (kidneys lose the ability to remove waste and balance fluids) and hypertension (elevated blood pressure). Further review of the closed clinical record on December revealed that Resident 1 attended dialysis on December 1, 2023, and on return from dialysis the facility did their routine COVID-19 test on Resident 1. The facility had active cases of COVID-19 during this time, so they were testing every Tuesday and Friday. Resident 1 tested positive for COVID-19 on Friday December 1, 2023, at 4:15 PM. During an interview with Employee 1 (Licensed Practical Nurse) on December 26, 2023, at 10:30 AM, she stated that the dialysis center was closed at the time Resident 1 tested positive, so she informed the next shift to notify dialysis on Saturday during the dialysis center's open hours. The facility was unable to provide any documentation or staff confirmation that the dialysis facility was made aware that Resident 1 was COVID-19 Positive. Documentation received from the dialysis center revealed they were never notified regarding Resident 1 testing positive for COVID-19, and were only made aware on December 13, 2023, when Resident 1 was sent to the hospital. Resident 1 attended dialysis on December 4, 6, and 8, 2023, and was placed in the waiting area with other residents at the dialysis center. Resident 1 refused dialysis on December 11, 2023, and when the facility notified the dialysis center of the cancellation there was no mention of COVID-19 positive status at that time per them dialysis center. During a telephone correspondence with the Registered Nurse at the Dialysis Center on December 28, 2023, at approximately 11:15 AM, the Registered Nurse said the dialysis center was made aware that the resident was COVID-19 positive through the hospital system when the resident was being transferred to the hospital. The dialysis center made a call to the ICP at the facility on December 13, 2023, (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395613 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395613 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Lakes Rehabilitation and Wellness Center 201 Franklin Farm Lane Chambersburg, PA 17201 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)