Mountain Laurel Healthcare: Medication Left Unsecured - PA
State inspectors observed it happening in real time on April 28, 2026, starting just after five in the evening.
At 5:01 p.m., inspectors found five pre-poured medication cups sitting on top of the medication cart. The cups held pills and liquids, each labeled with a first name. The cart was unlocked. Three of its drawers were ajar. The cups belonged to four residents, identified in the inspection report as Residents 1, 4, 10, and 17. A fifth resident, Resident 9, was seated nearby.
Then the nurse walked into a patient room and left the cart behind her, out of her sight, unsecured, with the medications sitting on top and Resident 9 still next to it.
This happened again at 5:07 p.m. Again at 5:15 p.m.
Each time, Licensed Practical Nurse 1 entered a resident's room to administer medications, leaving the cart in the hallway with pre-poured cups on top, drawers open, and no one watching it. Resident 9 remained beside the cart.
When inspectors interviewed the nurse at 5:21 p.m., she didn't dispute any of it. She said she pre-pours medications for some residents because they like to go to the dining room for supper and it is easier that way. She acknowledged she should not have left the cups unsecured on top of the cart when it wasn't in her direct line of sight. She acknowledged the cart should have been locked with all drawers closed when she stepped away.
Then she explained the situation with Resident 4.
That resident doesn't like to take lactulose, a laxative prescribed four times daily. So the nurse said she prepares it in advance to sneak it into his milk during the supper meal. Lactulose is typically prescribed to treat constipation or to reduce ammonia buildup in patients with liver conditions. Resident 4 was also prescribed potassium chloride twice daily, a supplement that can cause serious cardiac effects if taken incorrectly or by someone for whom it wasn't prescribed.
The nurse also explained the situation with Resident 17. That resident had been at the hospital for a procedure. The nurse said she had already prepared her medications before realizing she hadn't returned yet. Resident 17's pre-poured cup, containing metoprolol tartrate, a heart medication, and senna, a laxative, sat on top of the unlocked cart in the hallway for a patient who wasn't even in the building.
The four residents whose medications were pre-poured and left unsecured had been prescribed a combined total of more than a dozen drugs. Resident 1 was on clonazepam, a controlled benzodiazepine used to treat seizures and anxiety disorders, along with metformin, magnesium oxide, and Vitamin C. Resident 10 was on atorvastatin, Pepcid, and Ranexa, a medication used to treat chronic chest pain.
Clonazepam is a Schedule IV controlled substance. It carries a risk of dependence and is subject to specific storage requirements precisely because of its potential for misuse. The inspection report notes that the facility's own policy, dated March 19, 2026, required all drugs and biologicals to be stored in locked compartments during medication pass and kept under the direct observation of the nurse administering them. The policy was six weeks old when inspectors watched it being ignored.
The nursing home administrator confirmed the violation during an interview the same evening, at 6:48 p.m. The medications should not have been pre-poured, the administrator said. They should not have been left on the cart unsupervised. The cart should have been locked with all drawers closed any time it was out of the nurse's direct sight.
The inspection report cited four of 20 residents reviewed as affected. The level of harm was classified as minimal harm or potential for actual harm. That classification reflects what inspectors could document, not necessarily what the open cart and unsupervised medications represented to anyone who might have reached for them.
Resident 9 sat next to that cart for at least fourteen minutes.
The inspection was conducted as a complaint investigation. The deficiency was cited under Pennsylvania pharmacy services regulations. The facility's plan of correction was not included in the inspection materials reviewed.
Mountain Laurel Healthcare and Rehabilitation Center is located at 700 Leonard Street in Clearfield, a borough of roughly 6,000 people in central Pennsylvania. The facility had not responded to a request for comment by the time this article was published.
What the report leaves unresolved is simpler than any regulatory citation. A nurse pre-poured a controlled substance and left it sitting in an open cup on an unlocked cart in a hallway. She did it because it was easier. She prepared a heart patient's medications before the patient came back from the hospital. She prepared a laxative solution in advance so she could add it to another resident's milk without him knowing. And for at least part of those fourteen minutes, the only person near any of it was a resident who hadn't been prescribed any of it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mountain Laurel Healthcare and Rehabilitation Ctr from 2026-04-30 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 6, 2026 · Our methodology
MOUNTAIN LAUREL HEALTHCARE AND REHABILITATION CTR in CLEARFIELD, PA was cited for violations during a health inspection on April 30, 2026.
State inspectors observed it happening in real time on April 28, 2026, starting just after five in the evening.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.