Rittenhouse Post Acute: Seizure Meds Not Delivered - PA
The missed doses were documented in a nursing note written at 6:03 a.m. on August 10, 2025, nearly nine hours after both medications were due. "Patient did not receive seizure medications this shift," the nurse wrote. "Doctor made aware."
The resident, identified in inspection records only as Resident R1, had been prescribed two seizure medications starting the night of August 9. One was Lacosamide, a tablet she was supposed to receive every morning and every night. The other was Lamotrigine, prescribed at 125 milligrams at bedtime. Both orders carried a start date of August 9, 2025, at 9:00 p.m. Neither was given.
The Director of Nursing confirmed it during an interview with federal inspectors on August 19, 2025. The medications were not administered, she said, because they were never delivered by the pharmacy.
The facility's own policy, last revised in April 2019, states that pharmacy services are available to residents 24 hours a day, seven days a week, and that residents will receive medications, whether routine, emergency, or as needed, in a timely manner. On the night of August 9, none of that applied to Resident R1.
Inspectors rated the violation as causing minimal harm or potential for actual harm. What that rating does not capture is what it means to miss a bedtime dose of seizure medication. Lamotrigine and Lacosamide are both prescribed to suppress abnormal electrical activity in the brain. They are maintenance drugs, not optional. Missing a dose does not produce an immediate visible symptom in most cases. It raises risk.
The nursing note is the only documented response in the inspection record. A nurse wrote it. A doctor was notified. The medications were not given that night.
The inspection was conducted in response to a complaint and covered two residents. The pharmacy delivery failure was identified in one of them. Inspectors reviewed clinical records, facility policy, and interviewed staff. The finding was cited under F0755, which covers pharmaceutical services.
Rittenhouse Post Acute is a post-acute and rehabilitation facility in Philadelphia. The inspection was completed August 19, 2025.
What the record does not show is whether anyone at the facility contacted the pharmacy on the night of August 9 to request an emergency delivery, whether the resident experienced any adverse effects from missing both doses, or whether the physician who was notified at some point before 6:03 a.m. ordered any intervention. The inspection report does not address those questions. The nursing note ends with "Doctor made aware." That is where the documentation stops.
The facility's policy promised something specific: that no resident would go without prescribed medication because of a pharmacy failure. The policy exists. The pharmacy contract exists. The 24-hour availability guarantee exists in writing. On August 9, a resident with a seizure disorder went to bed without her seizure medications, and a nurse wrote it down hours later when the night shift was almost over.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rittenhouse Post Acute from 2025-08-19 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 5, 2026 · Our methodology
RITTENHOUSE POST ACUTE in PHILADELPHIA, PA was cited for violations during a health inspection on August 19, 2025.
The missed doses were documented in a nursing note written at 6:03 a.m.
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.