Sayre Health Care Center: Medication Errors - PA
Federal inspectors observed Employee 4 administer Sucralfate to Resident 59 at 8:09 AM on April 1 while the resident's breakfast tray sat in front of them on their bedside table. The resident had already eaten half of a pancake. The medication packaging clearly instructed that Sucralfate should be administered on an empty stomach.
Eighteen minutes later, the same nurse gave Bethanechol to Resident 10, who had eaten all their breakfast with the tray still positioned on their bedside table. The bladder medication's packaging also required administration on an empty stomach, at least one hour before or two hours after meals.
Sucralfate adheres to the stomach lining to protect it from acids and enzymes. When taken with food, the medication cannot properly coat the stomach to prevent ulcers from forming or worsening.
Employee 4 told inspectors at 8:36 AM that she was unaware of the special instruction packaging requirements for either medication.
The facility's overall medication error rate reached 7.41 percent based on 27 medication opportunities with two errors documented. Federal standards require nursing homes to maintain medication error rates below five percent to ensure resident safety.
Both violations occurred during a single medication administration pass that inspectors observed for less than 20 minutes. The concentrated timeframe suggests systemic problems with medication protocols rather than isolated incidents.
The nursing home's medication reference system, Drugs.com, explicitly states that both medications must be taken on empty stomachs. Bethanechol specifically requires a minimum one-hour gap before meals or two hours after eating to maintain effectiveness for treating bladder spasms and urinary retention.
When inspectors reviewed the medication errors with the Nursing Home Administrator and Director of Nursing at 12:30 PM that same day, the facility had already exceeded acceptable error thresholds by nearly 50 percent.
The violations indicate staff either ignored packaging instructions or failed to coordinate medication timing with meal schedules. Both residents received medications that could be significantly less effective or potentially harmful when administered with food.
Employee 4's admission that she was unaware of basic medication requirements raises questions about staff training and supervision protocols. Licensed practical nurses are required to understand medication administration guidelines before handling controlled substances and prescription drugs.
The 18-minute gap between the two observed errors suggests the nurse continued standard medication rounds without checking individual drug requirements or coordinating with meal service timing.
Federal inspectors classified the violations as causing minimal harm or potential for actual harm, but noted that some residents were affected by the facility's failure to maintain proper medication error rates.
The inspection occurred during morning medication administration, when nursing homes typically distribute the majority of daily medications to residents who have just finished breakfast. Proper timing requires either administering stomach medications before meals or waiting the required interval afterward.
Sayre Health Care Center's medication error rate of 7.41 percent means that for every 100 medication opportunities, more than seven result in mistakes that could compromise resident health or treatment effectiveness.
The facility must correct its medication administration protocols and ensure staff understand packaging instructions for commonly prescribed drugs. Both Sucralfate and Bethanechol are standard medications in nursing home settings, making the errors particularly concerning for inspectors.
Neither resident experienced documented immediate adverse effects, but the violations demonstrate gaps in basic pharmaceutical care that federal regulators monitor closely during nursing home inspections.
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.
The resident had already eaten half of a pancake.
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?
- The resident had already eaten half of a pancake.
- 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.