Mountain Laurel Healthcare And Rehabilitation Ctr
MOUNTAIN LAUREL HEALTHCARE AND REHABILITATION CTR in CLEARFIELD, PA — inspection on April 30, 2026.
Found 3 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
some vitamins in error to the wrong resident and stated that the resident gave her the name of
did not ask any other staff to identify Resident 12.A quarterly MDS assessment for Resident 14, dated
daily care needs. A nursing note, dated April 20, 2026 revealed that an interdisciplinary team reviewed an incident from April 17, 2026 regarding a medication error for Resident 14.
Upon investigation it was determined that resident was given 0.5 mg Clonazepam instead of 60 mg Morphine during morning medication pass. An admission MDS assessment for Resident 15, dated April 2, 2026, revealed that the resident was cognitively intact and was independent with daily care needs. A nursing note for Resident 15, dated April 16, 2026 revealed that the resident was given 5-325 mg of Hydrocodone/APAP (narcotic pain medication) instead of 5-325 mg of Oxycodone/APAP (narcotic pain medication).
Interview with the Nursing Home Administrator on April 28, 2026 at 6:43 p.m. confirmed that the above referenced medication errors should not have happened and that Resident 13's MAR should have been updated to reflect the correct times for administration and were not. 28 Pa.
Code 211.12(d)(3) Nursing services. 28 Pa.
Code 211.12(d)(5) Nursing services.
395331 04/30/2026
Mountain Laurel Healthcare and Rehabilitation Ctr 700 Leonard Street Clearfield, PA 16830
Based on review of policies, as well as observations and staff interviews, it was determined that the
(Residents 1, 4, 10, 17), and failed to ensure that the medication cart was secured when it was out of site.Findings include:The facility's policy regarding medication, dated March 19, 2026, indicated that all drugs and biologicals will be stored in locked compartments, such as medication carts and that during medication pass, medications must be under the direct observation of the person administering the medications or locked in the medication storage area/cart.Physician's orders for Resident 1, dated August 21, 2024 included an order for the resident to receive 1 milligram (mg) clonazepam two times per day; an order dated March 4, 2023 for the resident to receive 1000 mg metformin hydrochlorothiazide two times per day; an order dated January 13, 2026 for the resident to receive 400 mg magnesium oxide two times per day; and an order dated June 16, 2023 for the resident to receive 500 mg Vitamin C two times per day.Physician's orders for Resident 4, dated December 24, 2024 included an order for the resident to receive 20 milliequivalents (MEQ) potassium chloride two times per day and an order dated December 6, 2024 for the resident to receive 30 milliliters (ml) lactulose solution four times per day.
Physician's orders for Resident 10, dated May 15, 2025 included an order for the resident to receive 20 mg Atorvastatin at bedtime; an order dated May 28, 2025 for the resident to receive 40 mg Pepcid two times day; and an order for the resident to receive 1000 mg Ranexa every 12 hours.
Physician's orders for Resident 17, dated November 5, 2025 included an order for the resident to receive 12.5 mg Metoprolol Tartrate two times per day and an order dated November 5, 2025 for 8.6 mg Senna at bedtime.Observations during medication administration on April 28, 2026 at 5:01 p.m. revealed that there were five pre-poured medication cups with pills and liquids in them.
The cups had a first name printed on them and were sitting on top of the medication cart, unsecured.
The cups were identified as belonging to Residents 1, 4, 10, and 17.
The medication cart was unlocked and there were three drawers that were ajar. Resident 9 was observed sitting near the medication administration cart when Licensed Practical Nurse 1 left the cart unsupervised to enter a resident's room. At 5:01 p.m.
Licensed Practical Nurse 1 administered a cup of pre-poured medications to Resident 1. At 5:12 p.m.
Licensed Practical Nurse 1 administered a cup of pre-poured medications to Resident 4. At 5:07 p.m.
Licensed Practical Nurse left the medication cart and entered a resident's room.
The medication cart was out of her site. At 5:15 p.m.
Licensed Practical Nurse 1 left the medication cart in the hall with pre-poured medications sitting on top, unsecured, and the drawers to the cart ajar with Resident 9 sitting next to the cart.
Licensed Practical Nurse 1 entered another resident's room to administer medications, leaving the cart in the hall, unsecured and with pre-poured medications on top.
Interview with Licensed Practical Nurse 1 on April 28, 2026 at 5:21 p.m. revealed that she pre-pours her medications for some of the residents because they like to go to the dining room for supper and it is easier to do that.
She stated that she should not have left them unsecured on top of the medication cart when the cart was not in her direct line of site.
She further confirmed that she should not have left the medication cart unlocked with doors ajar when the cart was out of her direct line of sight.
She stated that R4 does not like to take the Lactulose so she has to have it prepared to sneak it into his milk during the supper meal.
She stated that Resident 17 was out at the hospital and that she had her medications prepared prior to realizing that she was not back yet from her procedure.Interview with the Nursing Home Administrator on April 28, 2026 at 6:48 p.m. confirmed that the medications should not have been pre-poured or left on the medication cart unsupervised and that the medication cart should have been locked with all drawers closed when not in direct sight of the nurse.28 Pa.
Code 211.9(a)(1) Pharmacy services.
395331 04/30/2026
Mountain Laurel Healthcare and Rehabilitation Ctr 700 Leonard Street Clearfield, PA 16830
administration of medications for two of 20 residents reviewed (Residents 2, 3).Findings include: The
remove medication from source, taking care not to touch the medication with their bare hand.
Observations during medication administration on April 28, 2026 at 5:15 p.m. revealed that Licensed Practical Nurse 1 was preparing to administer Resident 2's medications.
She popped a pill into her bare hand and then dropped it into the medication cup.
She then proceeded to administer the medication to Resident2.Observations on April 28, 2026 at 5:07 p.m. revealed that while popping the medications into Resident 3's medication cup a pill fell out of the cup and into the medication cart.
Licensed Practical Nurse 1 picked up the pill with her bared hand and placed it in the cup.
She then proceeded to administer the medication to Resident 3.Interview with Licensed Practical Nurse 1 on April 28, 2026 at 5:28 p.m. revealed that she should not have touched the pills with her bare hands and then administer them to the residents.Interview with the Nursing Home Administrator on April 28, 2026 at 6:44 p.m. confirmed that Licensed Practical Nurse 1 should not have touched pills with her bare hands and then administer them to the residents.28 Pa.
Code 211.12(d)(1) Nursing services.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.