Sayre Health Care Center: Medication Delays - PA
Resident 29 was supposed to receive potassium chloride tablets twice daily starting December 26, 2025, after a doctor ordered the medication for low potassium levels. Instead, nursing staff documented a pattern of delays that stretched from early January into late January 2026.
The medication administration record tells the story in staff's own words. January 3: "on order." January 5: "awaiting pharmacy." January 7: "awaiting pharmacy." January 12: "awaiting pharmacy."
By January 13, the notes grew more specific. At 10:05 AM, staff wrote: "Awaiting pharmacy. Unable to pull from pharmacy." That evening: "awaiting pharmacy."
The delays continued. January 15: "Awaiting pharmacy. Not available in cubex." January 16: "awaiting pharmacy." January 19: "not in pack, not available in cubex." January 20: "awaiting pharmacy, not available in cubex."
During this period, nurses filed three separate notification forms with the resident's physician about the missed doses. Each time, the doctor responded that it was "ok to administer when received from pharmacy."
The first notification, dated January 14, reported missed doses on January 12 and 13. A second form on January 17 documented missed doses on January 15 and 16, noting the medication "was not available in the cubex and awaiting refill." A third notification on January 20 reported additional missed doses on January 18 and 19.
Potassium chloride treats dangerously low potassium levels, which can cause irregular heartbeats, muscle weakness, and other serious complications. The extended-release tablets prescribed for Resident 29 deliver a controlled dose of the essential electrolyte.
When federal inspectors interviewed a registered nurse on April 2, 2026, the staff member explained that facility workers had "pulled out the available potassium chloride from the cubex and pharmacy was notified of this." The cubex is an automated medication dispensing system used in many nursing facilities.
The inspection report doesn't explain why the pharmacy took weeks to supply a commonly prescribed medication, or why facility staff didn't pursue alternative solutions during the extended delay. It also doesn't detail what, if any, monitoring was done of the resident's potassium levels during the three-week gap.
Federal regulations require nursing homes to provide pharmaceutical services that ensure "accurate acquiring, receiving, dispensing, and administering of all drugs." The facility failed to meet this standard for Resident 29, according to inspectors.
The violation was classified as causing "minimal harm or potential for actual harm" and affected "few" residents. However, the repeated documentation shows staff were aware of the problem for weeks without resolving it.
Sayre Health Care Center operates on Keefer Lane in this small Pennsylvania town near the New York border. The facility's administrators and director of nursing reviewed the findings with inspectors on April 1, 2026.
The inspection narrative doesn't indicate whether Resident 29 eventually received the prescribed potassium medication or experienced any medical complications from the delayed treatment. It also doesn't reveal whether other residents faced similar medication delays.
The case illustrates how administrative failures can leave vulnerable residents without prescribed medications for extended periods, even when staff document the problem daily in medical records.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sayre Health Care Center from 2026-04-03 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 14, 2026 · Our methodology
SAYRE HEALTH CARE CENTER in SAYRE, PA was cited for violations during a health inspection on April 3, 2026.
Instead, nursing staff documented a pattern of delays that stretched from early January into late January 2026.
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.
Frequently Asked Questions
- What happened at SAYRE HEALTH CARE CENTER?
- Instead, nursing staff documented a pattern of delays that stretched from early January into late January 2026.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in SAYRE, PA, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from SAYRE HEALTH CARE CENTER or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 395101.
- Has this facility had violations before?
- To check SAYRE HEALTH CARE CENTER's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.