AristaCare at East Falls: Medication Error Violation - PA
The hospital's After Visit Summary, dated November 4, 2025, instructed staff to discontinue clonazepam, Keppra, Seroquel, and valproic acid. The next day, a physician entered standing orders to administer all four. Keppra and valproic acid were given as ordered from November 5 through November 11, a full week after the hospital said stop.
The resident's family was at the bedside on November 6 and raised concerns about the medications. A progress note from that day, written by the facility's nurse practitioner, documented the family's worry and noted the resident was lethargic. The note also acknowledged the facility was still waiting on the proper medication list from the hospital.
That list never came — because nobody went and got it.
When inspectors interviewed the nurse practitioner on December 29, she acknowledged the facility did not have the hospital's discharge medication list when the resident arrived. She said she adjusted clonazepam and Seroquel to as-needed status after the family raised the alarm, and that she repeatedly reminded nursing staff to obtain the updated list. She also said she had no idea the hospital had ordered Keppra and valproic acid discontinued.
The two drugs she didn't know about were the ones given for seven straight days.
The inspection, conducted as a complaint investigation, cited the facility for a significant medication error affecting the resident. Inspectors classified the harm level as minimal, though the resident was documented as lethargic the day after admission while receiving medications a hospital had already ordered stopped. The family had noticed. The nurse practitioner had noticed something was wrong. The medication list existed. Nobody retrieved it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aristacare At East Falls from 2025-12-30 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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 19, 2026 · Our methodology
ARISTACARE AT EAST FALLS in PHILADELPHIA, PA was cited for violations during a health inspection on December 30, 2025.
The hospital's After Visit Summary, dated November 4, 2025, instructed staff to discontinue clonazepam, Keppra, Seroquel, and valproic acid.
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.