Home / Pennsylvania / Clearfield
Mountain Laurel Healthcare and Rehabilitation Ctr
700 Leonard Street, Clearfield, PA 16830 · Clearfield County · (814) 765-7545
240 certified beds, about 128 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1975
Certified for Medicaid Certified for Medicare
Overall
2 of 5
Health inspections
1 of 5
Staffing
2 of 5
Quality measures
5 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 395331 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on July 23, 2026, inspectors cited 19 health deficiencies (the Pennsylvania average is 10, the national average 9.2).
Of 66 health citations since October 2023, 2 were rated as actual harm or immediate jeopardy to residents.
CMS lists 1 fine totaling $8,190 in the last three years; the largest was $8,190, and the latest is dated October 5, 2023.
Nurses and nurse aides worked 3.27 hours per resident per day, against 3.89 across Pennsylvania and 3.86 nationally. Registered nurses accounted for 0.46 of those hours.
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
110/23
112/23
102/24
205/24
1509/24
1408/25
212/25
103/26
304/26
105/26
306/26
307/26
1907/26
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 66 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
36D
28E
0F
Potential for minimal harm
0A
0B
0C
July 23, 2026Standard inspection, Complaint inspection · 19 citations
- E Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased 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.
- E Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to provide a homelike environment for the residents in the facility's second floor dining room.
- E Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on a review of facility policies and clinical records, as well as staff interviews, it was determined the facility failed to ensure a resident's medication regimen was free from unnecessary psychotropic medications for one of 87 residents reviewed (Resident 59).
- E Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual and clinical records, the Centers for Medicare &; Medicaid Services (CMS) Minimum Data Set (MDS) validation report, as well as staff interviews, it was determined that the facility failed to ensure that the Care Area Assessment Process of comprehensive Minimum Data Set assessments and comprehensive assessments were completed in the required time frame for 16 of 87 residents reviewed (Residents 9, 57, 83, 97, 98, 129, 152, 153, 157, 159, 162, 163, 165, 170, 171, 172).
- E Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on clinical record reviews, as well as resident and staff interviews, it was determined that the facility failed to implement an individualized care plan for dental needs for eight of 87 residents reviewed (Residents 4, 25, 56, 59, 129, 135, 162, 171).
- E Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on a review of facility policies and clinical record review, as well as resident and staff interviews, it was determined that the facility failed to ensure that residents were assessed and received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of Post Traumatic Stress Disorder (PTSD) (a mental and behavioral disorder that develops related to a terrifying event) for three of 87 residents reviewed (Resident 7, 25, and 129).
- E Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on review of personnel files, as well as staff interviews, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed at least annually for five of five nurse aides reviewed (Nurse Aide 1, Nurse Aide 2, Nurse Aide 3, Nurse Aide 4, and Nurse Aide 5).
- E Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observations, and a test tray, as well as resident and staff interviews, it was determined that the facility failed to serve food that was palatable.
- E Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on review of manufacturer's recommendations, observations, and staff interviews, it was determined that the facility failed to ensure that the dishwashing temperatures were at proper temperatures to ensure sanitary dishwashing conditions.
- D Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to provide the required notice to the resident or the resident's representative following the end of their Medicare coverage for three of three residents reviewed (Residents 10, 14, 46) who remained in the facility for long-term care.
- D Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on review of the Resident Assessment Instrument Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required time frame for seven of 87 residents reviewed (Residents 56, 74, 85, 96, 119, 130, 141).
- D Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on a review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's baseline care plan included information regarding the resident's immediate care needs for one of 87 residents reviewed (Residents 155).
- D Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to clarify a provider's orders for one of 80 residents reviewed (Resident 136).
- D Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that pressure ulcer care/prevention treatments were provided as ordered for one of 80 residents reviewed (Resident 9).
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on facility policy, clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure a safe environment for three of 87 residents reviewed (Residents 133, 169, and 171).
- D Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to respond to a pharmacy recommendation for two of 87 residents reviewed (Residents 7, 13) and failed to ensure that monthly pharmacy medication reviews were completed for one of 87 residents reviewed (Resident 56).
- D Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.
- D Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to use proper infection control practices during incontinent care for one of 80 residents reviewed (Resident 9).
- D Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that each resident was offered and/or received the influenza and/or the pneumococcal immunizations for four of 87 residents reviewed (Residents 1, 4, 113, 171).
July 9, 2026Complaint inspection · 3 citations
- E Ensure that a resident does not develop patterns of decreased social interaction and/or increased withdrawn, angry, or depressive behaviors, unless unavoidable.
Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to monitor, assess and analyze, and attempt new interventions for a resident's increased verbal, physically-aggressive behaviors, and sexual behaviors for one of seven residents reviewed (Resident 1).
- E Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to provide appropriate treatment and services for 51 residents who reside on the secured memory impaired unit.
- D Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on review of policies and personnel files, as well as staff interviews, it was determined that the facility failed to complete a professional licensure verification with the Pennsylvania State Board of Nursing prior to hire for two of five employees reviewed (Registered Nurses 4 and 5), failed to complete a Pennsylvania Nurse Aide registry check prior to hire for one of five employees reviewed (Nurse Aide 3) and failed to perform a Pennsylvania criminal background check for two of five employees reviewed (Dietary Aides 1 and 2).
June 5, 2026Complaint inspection · 3 citations
- E Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications (drugs with the potential to be abused) for three of eight residents reviewed (Residents 5, 7, 8).
- D Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Inspectors wroteBased on a review of policies and clinical record reviews, as well as staff interviews, it was determined that the facility failed to readmit a resident following a hospitalization for one of eight residents reviewed (Resident 1).
- D Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on review of clinical records, as well as staff interviews, it was determined that the facility failed to notify the resident and/or the resident's representative, in writing regarding the reason for transfer to the hospital and failed to notify the ombudsman of the transfer to the hospital, for two of eight residents reviewed (Residents 1, 6).
May 12, 2026Complaint inspection · 1 citation
- D Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on review of policies, information provided by the facility, as well as staff interviews, it was determined that the facility failed to make prompt efforts to resolve grievances regarding concerns voiced by residents during resident council meetings.
April 30, 2026Complaint inspection · 3 citations
- E Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed for two of 20 residents reviewed (Residents 8, 13) and failed to ensure medications were administered to the correct resident for three of 20 residents reviewed (Residents 12, 14, 15), resulting in medication errors.
- E Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly secured for four of 20 residents reviewed (Residents 1, 4, 10, 17), and failed to ensure that the medication cart was secured when it was out of site.
- D Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of policies, observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices and techniques were followed during the administration of medications for two of 20 residents reviewed (Residents 2, 3).
March 19, 2026Complaint inspection · 1 citation
- G Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased 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.
December 16, 2025Complaint inspection · 2 citations
- D Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to employ sufficient staff with appropriate competencies and skills sets to carry out the functions of the food and nutrition service.
- D Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on review of facility reports as well as interviews with staff, it was determined that the governing body/owners failed to assume responsibility for effective management of the facility to ensure that it operated in compliance with state regulations and codes.
August 14, 2025Standard inspection, Complaint inspection · 14 citations
- E Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to provide a dining experience based upon resident's preference for 5 of 50 residents reviewed (Residents 46, 69, 81, 83, 95).
- E Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to provide a clean and homelike environment in residents' rooms for six of 50 residents reviewed (Residents 23, 24, 40, 48, 90, 105).
- E Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on review of clinical records and staff interviews, it was determined that the facility failed to ensure that proper care to prevent infection was provided for one of 50 residents reviewed (Resident 23).
- E Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide showers as scheduled for 5 of 50 residents reviewed (Residents 17, 71,77, 86, 100) and failed to have sufficient staff to have the first floor main dining room open for 5 of 50 residents reviewed (Residents 46, 69, 81, 83, 95).
- E Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to respond to a pharmacy recommendation for one of 50 residents reviewed (Resident 46) and failed to provide a rationale for not referring the resident to psychiatric care per pharmacist's recommendations (R8).
- E Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to store and serve food in accordance with professional standards for food service safety.
- E Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteBased on a review of a list of nurse aides currently employed by the facility, including their hire dates and training hours, as well as staff interviews, it was determined that the facility failed to ensure that nurse aides had 12 hours of in-service training annually for four of four nurse aides reviewed (Nurse Aide 6, Nurse Aide 7, Nurse Aide 2, and Nurse Aide 8).
- D Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the physician was notified timely about a change in condition for one of 50 residents reviewed (Resident 58).
- D Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on clinical record review, as well as staff interviews, it was determined that the facility failed to notify the resident's representative in writing regarding the reason for transfer to the hospital and to ensure that a bed-hold notice was provided to the resident's responsible party for two of 50 residents reviewed (Residents 22 and 46). Findings Include:A nursing note for Resident 22 dated, April 11, 2025, at 3:47 a.m. revealed that the resident was moaning in pain. The facility attempted to contact her son three times without a response, and new orders were given by the medical doctor to send Resident 22 to the emergency room. Review of Resident 22's clinical record revealed no documented evidence that that resident representative was notified in writing of the transfer to the hospital, and there was no documented evidence that a bed hold notice was provided. [...]
- D Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that physician's orders for enteral tube feedings (feeding through a tube inserted directly into the stomach) was followed for one of 50 residents reviewed (Resident 7).
- D Ensure that residents are free from significant medication errors.
Inspectors wroteBased on a review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to ensure that it was free from significant medication errors for one of 50 residents reviewed (Resident 58).
- D Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on review of policies, manufacturer's instructions and clinical records, as well as observations and staff interviews, it was determined that the facility failed to date an opened insulin pen injector for one of 50 residents reviewed (Resident 18).
- D Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Inspectors wroteBased on clinical record reviews and observations, as well as resident and staff interviews, it was determined that the facility failed to ensure that drink preferences were honored for 2 of 50 residents reviewed (Residents 71, 101).
- D Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.
September 26, 2024Standard inspection · 15 citations
- E Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to provide medications as ordered by the physician for two of 44 residents reviewed (Residents 55, 84).
- E Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide appropriate care to prevent urinary tract infections for one of 44 residents reviewed (Resident 118) who had an indwelling urinary catheter.
- E Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to ensure that residents were assessed and received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of Post Traumatic Stress Disorder (PTSD - a mental and behavioral disorder that develops related to a terrifying event) for one of 44 residents reviewed (Resident 4).
- E Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on review of facility policies, clinical records, and investigation reports, as well as staff interviews, it was determined that the facility failed to provide the necessary services and failed to make certain appropriate treatment and services for dementia were provided to ensure the safety for one of 44 residents reviewed (Resident 109).
- E Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Inspectors wroteBased on observations, as well as resident and staff interviews, it was determined that the facility failed to have sufficient dietary staff to enable the main dining room to be open for meal times.
- E Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on review of faciliy policy, observations, and staff interviews, it was determined that the facility failed to prepare and store ice under sanitary conditions for one of three ice machines (second floor kitchenette) and failed to maintain a sanitary refrigerator on the first floor kitchenette.
- E Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.
- D Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on a review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to protect the residents rights for one of 44 residents reviewed (Resident 47).
- D Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on review of facility policies, investigation reports, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of 44 residents reviewed (Resident 58).
- D Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on review of clinical records, as well as staff interviews, it was determined that the facility failed to notify the state ombudsman and/or the resident and resident's responsible party in writing regarding the reason for transfers/discharge to the hospital for five of 44 residents reviewed (Residents 30, 44, 48, 56, 118).
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that resident-centered care plans were developed and implemented for three of 44 residents reviewed (Residents 4, 47, 111) regarding Post Traumatic Stress Disorder (PTSD), dialysis, and smoking.
- D Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for three of 44 residents reviewed (Residents 44, 90, 109).
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on review of facility policy, clinical record reviews, and resident and staff interviews, it was determined that the facility failed to ensure a safe environment related to smoking for one of 44 residents reviewed (Resident 46).
- D Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on review of manufacturer's instructions and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain a medication administration error rate of less than five percent.
- D Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that each resident was offered and/or received the influenza immunizations for one of 44 residents reviewed (Resident 14).
May 2, 2024Complaint inspection · 2 citations
- D Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident's responsible party was notified about the need to alter treatment or medications for two of eight residents reviewed (Residents 2, 5).
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on review of clinical records and facility investigation reports, as well as staff interviews, it was determined that the facility failed to ensure that the resident environment remained free of accident hazards by failing to ensure that a resident's swallowing ability was assessed for potential safety hazards for one of eight residents reviewed (Resident 2).
February 5, 2024Complaint inspection · 1 citation
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the residents' environment remained free of accident hazards for one of six residents (Resident 2) identified as an elopement risk.
December 1, 2023Complaint inspection · 1 citation
- G Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased 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.
October 5, 2023Complaint inspection · 1 citation
- D Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on a review of policies, as well as interviews with residents and staff, it was determined that the facility failed to ensure that residents and/or their representatives could file a grievance/concern anonymously by failing to ensure that concerns brought to staff were investigated even if the residents did not want their name listed on a form.
Fire safety inspections
29 fire safety citations on file: 9 on July 23, 2026, 12 on August 14, 2025, 8 on September 26, 2024.
Every fire safety citation29 citations
- F Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- F Have simulated fire drills held at unexpected times.
- D Meet other general requirements.
- D Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- C Establish emergency prep training and testing.
- C Provide properly protected cooking facilities.
- C Install a fire alarm system that can be heard throughout the facility.
- C Ensure that HVAC heat units are suspended and out of the reach of patients and can be shut off if unit is working improperly.
- C Have proper medical gas storage and administration areas.
- F Have approved installation, maintenance and testing program for fire alarm systems.
- F Inspect, test, and maintain automatic sprinkler systems.
- F Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- F To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- F Have generator or other power source capable of supplying service within 10 seconds.
- F Have proper medical gas storage and administration areas.
- C Establish policies and procedures for sheltering.
- C Establish emergency prep training and testing.
- C Establish staff and initial training requirements.
- C Conduct testing and exercise requirements.
- C Provide properly protected cooking facilities.
- B Properly select, install, inspect, or maintain portable fire extinguishes.
- F Provide properly protected cooking facilities.
- D Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- D Inspect, test, and maintain automatic sprinkler systems.
- D Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- C Establish emergency prep training and testing.
- C Conduct testing and exercise requirements.
- C Meet other general requirements.
- B Install corridor and hallway doors that block smoke.
Fines and payment denials
| Date | Penalty | Amount or length |
|---|---|---|
| October 5, 2023 | Fine | $8,190 |
| October 5, 2023 | Payment Denial | 47 days from January 5, 2024 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Pennsylvania | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.27 | 3.89 | 3.86 |
| Registered nurses | 0.46 | 0.79 | 0.69 |
| All nursing staff on weekends | 2.96 | 3.53 | 3.42 |
| Nurse aides | 1.81 | ||
| Licensed practical nurses | 1.00 | ||
| Nursing staff turnover (share who left in a year) | not reported | 44.5% | 45.8% |
| Registered nurse turnover | not reported | 39.9% | 42.9% |
| Administrators who left | 2 |
CMS expects 3.28 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.40 on weekdays and 2.96 on weekends, 13% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 13.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.73 in April to June 2025 to 3.27 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.27 | 0.46 | 3.40 | 2.96 | 13.0% | 0 of 90 | 128 |
| Oct to Dec 2025 | 3.15 | 0.45 | 3.31 | 2.76 | 9.1% | 0 of 92 | 103 |
| Jul to Sep 2025 | 3.69 | 0.58 | 3.80 | 3.41 | 0.7% | 0 of 92 | 105 |
| Apr to Jun 2025 | 3.73 | 0.43 | 3.91 | 3.28 | 0.0% | 0 of 91 | 104 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Pennsylvania, Jan to Mar 2026 | 3.69 | 0.65 | 3.82 | 3.34 | 11.3% | 0.1% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Pennsylvania | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 14.6 | 16.8 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.0 | 0.7 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 1.6 | 1.4 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 3.3 | 3.1 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.9 | 1.4 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 13.6 | 17.0 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 6.2 | 4.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 22.8 | 17.7 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 4.8 | 22.5 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 4.2 | 9.5 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.7 | 1.6 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.0 | 1.2 | 1.8 |
Owners and operators
Legal business name: MOUNTAIN LAUREL OPCO LLC.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Mountain Laurel Opcp Holdco LLC | 5% or greater direct ownership interest | Organization | 100% | 12/15/2021 |
| Bl Panho Trust | 5% or greater indirect ownership interest | Organization | 12/15/2021 | |
| Mlspa LLC | 5% or greater indirect ownership interest | Organization | 12/15/2021 | |
| Mlspa Trust | 5% or greater indirect ownership interest | Organization | 12/15/2021 | |
| Mvrk I LLC | 5% or greater indirect ownership interest | Organization | 12/15/2021 | |
| Panho Capital Group LLC | 5% or greater indirect ownership interest | Organization | 12/15/2021 | |
| Garbacz, Andrew | 5% or greater indirect ownership interest | Individual | 12/15/2021 | |
| Gottesman, Daniel | 5% or greater indirect ownership interest | Individual | 12/15/2021 | |
| Kolman, Robert | 5% or greater indirect ownership interest | Individual | 12/15/2021 | |
| Plasschaert, Gary | W-2 managing employee | Individual | 12/15/2021 | |
| Kolman, Robert | Corporate officer | Individual | 12/15/2021 | |
| Premier Management Support LLC | Operational/managerial control | Organization | 12/15/2021 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 16 problems in this area, most recently on July 23, 2026: "Provide care or services that was trauma informed and/or culturally competent."
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 14 problems in this area, most recently on July 23, 2026: "Honor the resident's right to organize and participate in resident/family groups in the facility."
- When is the care plan meeting, and can family attend it?Inspectors cited 7 problems in this area, most recently on July 23, 2026: "Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months."
- Can we see a week of menus and the kitchen, and how are special diets handled?Inspectors cited 7 problems in this area, most recently on July 23, 2026: "Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature."
- Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 2.96 hours per resident per day, below the Pennsylvania average of 3.53.
- How long has the current administrator been here?CMS counts 2 administrators who left in the period it measured.
Other nursing homes nearby
- Ava Nursing and Rehab Center Curwensville, 6.8 mi · 1 of 5 stars · 53 citations
- Heritage Ridge Senior Living at Windy Hill Philipsburg, 13.4 mi · 2 of 5 stars · 39 citations
- Dubois Nursing Home Dubois, 18.5 mi · 1 of 5 stars · 50 citations
- Christ the King Manor Dubois, 20.7 mi · 4 of 5 stars · 7 citations
Pennsylvania contacts for a concern about a nursing home
These are the official offices in Pennsylvania. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Pennsylvania Department of Health, Division of Nursing Care Facilities, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Pennsylvania Long-Term Care Ombudsman Program, Department of Aging, 717-783-8975. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: Pennsylvania Department of Health Nursing Care Facility Locator, where Pennsylvania publishes its own records on licensed homes.
Common questions
- What is Mountain Laurel Healthcare and Rehabilitation Ctr's Medicare star rating?
- CMS rates Mountain Laurel Healthcare and Rehabilitation Ctr 2 out of 5 stars overall, with 1 for health inspections, 2 for staffing and 5 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Mountain Laurel Healthcare and Rehabilitation Ctr get at its last inspection?
- 19 health deficiencies at the standard inspection on July 23, 2026. The Pennsylvania average is 10.
- Has Mountain Laurel Healthcare and Rehabilitation Ctr been fined?
- Yes. CMS lists 1 fine totaling $8,190 in the last three years.
- Does Mountain Laurel Healthcare and Rehabilitation Ctr accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Mountain Laurel Healthcare and Rehabilitation Ctr?
- CMS lists 12 owners and managers. Legal business name: MOUNTAIN LAUREL OPCO LLC.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.