LeTort Spring Nursing and Rehab: Medication Failures - PA
That was the explanation offered on January 29, 2026, when inspectors pressed the Director of Nursing at LeTort Spring Nursing and Rehab about why a resident had gone without their seizure medication for days. The pharmacy confirmed it themselves: a current prescription for lacosamide, an anti-seizure drug, had been sitting in their system when nursing staff reordered it on January 12. Pharmacy staff overlooked it. The medication was never filled. The facility didn't follow up.
Lacosamide is prescribed to control seizures. Running out of it is not a minor inconvenience.
Nursing staff had reordered the medication on January 12, three days before the resident's supply was set to run out. The Director of Nursing told inspectors she would have expected staff to follow up with the pharmacy when the medication didn't arrive. That follow-up never happened. According to the inspection report, there was no documentation of any contact between the facility and the pharmacy from January 12 until January 17, when the resident's supply had already been exhausted.
The facility did have lacosamide locked in an emergency medication supply on-site. Nursing staff couldn't get to it. The pharmacy controls access through an authorization code, and the pharmacy said it wouldn't issue one because it didn't have a current prescription on file. That was wrong, as it turned out, but nobody caught the error until January 18, when the resident's physician submitted a new prescription and the pharmacy then acknowledged it already had one. The medication had been sitting there, unfilled, for six days.
The Director of Nursing confirmed all of this to inspectors. She confirmed she would have expected the pharmacy to either deliver medications on time or notify the facility immediately if there was a problem. Neither happened. She confirmed she would have expected nursing staff to follow up. They didn't.
The inspection report classified the violation as causing actual harm.
A second resident at the same facility ran into a different version of the same problem the same week.
That resident, who had diagnoses of dementia and anxiety disorder, had a standing order for Xanax, 0.5 milligrams every eight hours. On the morning of January 26, a licensed practical nurse documented that the dose had not been administered because the facility was waiting on pharmacy delivery. The pharmacy had actually filled the prescription the day before, on January 25, but the Receipt Verification section of the controlled substance record was left blank. Nobody had confirmed the medication arrived.
By the afternoon of January 26, a registered nurse was on the phone with the pharmacy trying to pull Xanax from the emergency supply. The pharmacy said no, because the medication had to be dispensed exactly as written, and the only tablets available in the emergency supply were 0.25 milligrams, not 0.5. The nurse had asked whether two of the smaller tablets could be given to equal the ordered dose. The pharmacy said the prescription had to be dispensed as written.
The nurse then called the resident's physician, who issued a one-time order for two 0.25-milligram tablets. That dose was administered at 6:30 in the evening. The resident had missed at least the morning dose, and possibly more.
When inspectors asked about the delay, the Director of Nursing confirmed she would expect staff to reorder medications when down to a five-day supply, and she would expect the pharmacy to deliver on time or communicate problems immediately. At the time of the interview, no one could say when nursing staff had reordered the Xanax, or why the pharmacy had been late delivering it.
The Director of Nursing also confirmed that staff are expected to complete the Receipt Verification section of the controlled substance record when a controlled medication arrives. It had been left blank.
The inspection covered both residents under a single deficiency finding. The facility's pharmacy services, nursing services, and management practices were all cited under Pennsylvania health code.
What the inspection report doesn't say is what the resident without seizure medication experienced during those days. It doesn't say whether they seized. It records the gap, the phone calls that weren't made, the prescription that was overlooked, the emergency cabinet that stayed locked. It records that the Director of Nursing, when asked, confirmed what should have happened. None of it had.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Letort Spring Nursing and Rehab LLC from 2026-01-29 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: August 16, 2026 · Our methodology
LeTort Spring Nursing and Rehab LLC in CARLISLE, PA was cited for violations during a health inspection on January 29, 2026.
The medication was never filled.
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.