Logan Square Rehab: Midnight Medication Delays - PA
The pattern wasn't isolated to one person. Inspectors reviewed medication administration records for five residents, labeled R1 through R5 in the report, and confirmed the same problem repeated across all of them.
For one resident, the delays ran like this: on August 20, their scheduled midnight dose didn't arrive until 2:46 a.m. The following night, the same dose wasn't given until 6:48 a.m. On August 22, it came at 7:08 a.m. On August 23, at 2:19 a.m.
That's a seven-hour delay, then a seven-hour delay again, on back-to-back nights.
The inspection was triggered by a complaint and conducted on August 28, 2025. Inspectors cited the facility under F0684, which covers quality of care, at a harm level described as minimal harm or potential for actual harm. Several residents were affected.
The Director of Nursing sat down with inspectors that afternoon and reviewed the facility's own medication administration policy. The policy includes what the facility calls "flexible administration times," meaning doses don't have to be given at the exact minute they're scheduled. The Director of Nursing confirmed, on review, that the delays inspectors documented fell outside even those flexible windows.
That confirmation matters. The facility's own standard, as reviewed and acknowledged by its own nursing director, wasn't met.
Tylenol, used to manage pain, is often scheduled at specific intervals to maintain consistent relief. A dose meant for midnight that doesn't arrive until nearly 7 a.m. is a dose that covers a different part of the day entirely. Whether residents were awake and waiting, or in pain and unable to summon help effectively during overnight hours, the inspection report doesn't say. What it does say is that the medication records for five residents confirmed the pattern.
The report doesn't name the residents, describe their conditions, or explain why nursing staff missed the scheduled times repeatedly. It doesn't say whether anyone complained, whether residents were harmed, or whether the facility had identified the problem before inspectors arrived.
What the records show is a facility where the overnight shift, across multiple residents and multiple nights in the same week of August, failed to administer a basic scheduled medication within the time its own policy required.
Logan Square Rehabilitation and Healthcare Center is located in the Logan Square neighborhood of Philadelphia. The inspection covered under this report was a complaint investigation, meaning someone, whether a resident, family member, or staff, contacted regulators before inspectors came through the door.
The Director of Nursing did not dispute the findings. The audit reports were reviewed together with inspectors, and the delays were confirmed.
For the residents whose records showed doses arriving at 6:48 a.m. and 7:08 a.m. instead of midnight, those are not close calls or minor scheduling hiccups. Those are gaps of more than six hours on scheduled overnight medication. Whatever those residents needed that medication for, they went without it through the night.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Logan Square Rehabilitation and Healthcare Center from 2025-08-28 including all violations, facility responses, and corrective action plans.
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 30, 2026 · Our methodology
LOGAN SQUARE REHABILITATION AND HEALTHCARE CENTER in PHILADELPHIA, PA was cited for violations during a health inspection on August 28, 2025.
The pattern wasn't isolated to one person.
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.