Laurel Square Healthcare: Lost Eye Drops, ER Visit - PA
The resident, identified in the report as Resident R1, first complained of left eye redness on October 22, 2025. A physician was notified that same day and ordered tobramycin ophthalmic solution, an antibiotic eye drop, to be given four times a day for five days. The prescription never reached her.
According to R1, the overnight nurse lost the eye drops after they were first ordered. When staff tried to get the prescription reordered, the facility ran into an insurance problem: the insurer wouldn't pay for the same prescription twice in one week.
So nothing happened. Day after day, the electronic medication administration record logged the same result: open space, an X, or a 9, the facility's notation for medication not given. Nursing notes from October 23 through October 27 document the same explanation each time, that the eye drops were on order and had not arrived.
They were ordered October 22. They didn't arrive until November 3.
By then, R1 had already been gone for a day. On November 2, after eleven days without the medication her doctor had prescribed, she demanded to go to the emergency room. "Her eye got so bad that it was bright red," she told inspectors during an interview on the morning of November 6. Once she started using the eye drops from the hospital, she said, her eye began clearing up.
The floor nurse responsible for R1's medications confirmed the timeline. The eye drops were ordered October 22, she told inspectors, but didn't come in until November 3. By that point, the resident had already gotten them from the ER.
The unit manager confirmed the same thing: the eye drops never came in through the facility. R1 saw an eye doctor on November 5, and a second eye drop, this one without the antibiotic, was ordered. As of the inspection date, that prescription had not arrived either.
The facility's administrator, interviewed that afternoon, confirmed that after eleven days with no treatment, the resident had to go to the emergency room to obtain medication that had been prescribed to her on the first day. The administrator told inspectors she was not satisfied with how the pharmacy handled the situation.
The inspection report, a complaint-based survey, cited the facility under Pennsylvania pharmacy and nursing services regulations. Inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents.
What the report describes is a narrow but complete failure: a prescription written, a medication lost, a reorder blocked by an insurance technicality, and nearly two weeks of documented inaction while a resident's eye worsened. The facility's own policy states that medications are to be administered in a safe and timely manner, as prescribed. R1's medication administration record shows dose after dose, four times a day, that never happened.
She sat in that facility for eleven days with a prescription on file and nothing in her eye. Then she went to the emergency room and got it herself.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Laurel Square Healthcare and Rehabilitation Center from 2025-11-06 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: June 22, 2026 · Our methodology
LAUREL SQUARE HEALTHCARE AND REHABILITATION CENTER in PHILADELPHIA, PA was cited for violations during a health inspection on November 6, 2025.
The resident, identified in the report as Resident R1, first complained of left eye redness on October 22, 2025.
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.