WILKES-BARRE, PA - Federal inspectors found that The Gardens At East Mountain nursing home failed to ensure timely medication delivery for multiple residents, including delayed pain management for a patient recovering from hip fractures and missed anxiety medication for a resident with chronic lung disease.
Medication Delivery Failures Leave Residents Without Essential Drugs
The March 2025 inspection revealed that three residents experienced significant delays in receiving prescribed medications due to pharmacy delivery problems and inadequate emergency medication supplies. The violations occurred despite facility policies stating that emergency pharmaceutical services should be available 24 hours a day.
Resident 90, who has chronic obstructive pulmonary disease along with depression and anxiety, was prescribed Clonazepam 1 mg twice daily for anxiety management on February 4, 2025. However, the medication was not administered as prescribed due to pharmacy delivery delays, leaving the resident without this anti-anxiety medication when needed.
The most serious case involved Resident 64, who sustained hip and pelvic fractures after a fall on February 23, 2025. Upon returning from the hospital on February 24, the resident had physician orders for Oxycodone 5 mg every four hours as needed for moderate pain. Despite receiving two doses of the pain medication in the hospital, the facility failed to provide the medication for three consecutive days - February 24, 25, and 26.
Nursing documentation from February 27 revealed the severity of the situation: the resident "exhibited increased confusion throughout the night, reporting visual hallucinations of children in her room. She remained awake all night and was unable to be redirected or oriented to time and place." The notes indicated the resident "complained of pain and was given Tylenol instead of Oxycodone" because the pain medication was not available at the facility.
Resident 201 faced delays with multiple essential medications on January 15, 2025, including Diltiazem for hypertension, Levothyroxine for thyroid management, and Oxycodone-Acetaminophen for pain management. These medications were not available until the following day due to pharmacy delays.
Medical Consequences of Medication Delays
Delayed medication administration can have serious medical consequences, particularly for the medications involved in these cases. Clonazepam withdrawal can cause increased anxiety, agitation, and potentially dangerous seizures in some patients. For residents with existing anxiety disorders and respiratory conditions, missing anti-anxiety medication can exacerbate breathing difficulties and increase distress.
Pain medication delays following orthopedic surgery represent a particularly concerning issue. Inadequate pain control after hip fractures can lead to several complications including delayed mobility, increased risk of pneumonia, blood clots, and delirium - which appeared to manifest in Resident 64's hallucinations and confusion. Proper pain management is essential for rehabilitation and preventing further complications in elderly patients recovering from fractures.
Thyroid medication like Levothyroxine must be taken consistently to maintain proper hormone levels. Missing doses can affect metabolism, heart function, and cognitive abilities. Similarly, blood pressure medications like Diltiazem require consistent administration to prevent cardiovascular complications.
Emergency Medication System Failures
The inspection revealed significant problems with the facility's emergency medication supply system. The Director of Nursing confirmed that when medications are unavailable from the pharmacy, staff should check the emergency supply, and if unavailable there, consult with physicians for alternatives. However, none of the needed medications were available in the emergency supply.
More concerning was the discovery that the facility's automated medication dispensing system contained serious discrepancies. Inspectors found that medication expiration dates in the system did not match the actual dates on medications, and medications listed as available were not physically present in the machine.
State regulations require monthly inspections of automated medication systems by pharmacist personnel, with documentation of oversight activities. However, the facility could not provide documentation of these required monthly audits or proper pharmacy oversight.
Regulatory Violations and Pharmacy Oversight Issues
The facility violated Pennsylvania Code Title 49, which requires that automated medication systems operate under pharmacist supervision with proper accountability measures. The regulations mandate that pharmacists ensure monthly inspections for expiration dates and system security, maintain audit trails of all transactions, and provide training to facility staff.
During interviews, the Director of Nursing and Administrator acknowledged that the facility relied solely on an out-of-state pharmacy with daily courier deliveries and did not have a backup emergency pharmacy as required by their own policies. They confirmed that facility nursing staff, rather than trained pharmacy personnel, were responsible for restocking the automated system without receiving proper training from pharmacists.
The facility's policy stated that a corporate pharmacist should be available 24/7 to either dispense medications or arrange for dispensing from a backup pharmacy, but administrators confirmed no such backup system existed.
Dental Care Deficiencies
In addition to medication issues, the inspection found that the facility failed to offer routine annual dental services to three residents. Two private-pay residents and one Medicaid recipient had no documentation showing their responsible parties were consulted about dental services in the past year.
Oral health is particularly important for nursing home residents, as poor dental hygiene can lead to infections, difficulty eating, and increased risk of pneumonia. Federal and state regulations require facilities to either provide or arrange for dental services and to offer routine dental care annually.
Additional Issues Identified
The inspection also documented violations related to resident rights and social services, though specific details of these violations were not detailed in the available documentation. These violations, combined with the medication and dental care issues, indicate broader systemic problems with the facility's compliance with federal nursing home regulations.
The facility's inability to maintain proper pharmacy services represents a fundamental failure in providing basic nursing home care. Consistent medication administration is essential for managing chronic conditions, preventing complications, and maintaining quality of life for nursing home residents.
Proper pharmaceutical services require not only reliable medication delivery but also appropriate emergency supplies, trained staff, and documented oversight procedures. The violations at The Gardens At East Mountain demonstrate how failures in these systems can directly impact resident health and safety, leaving vulnerable patients without essential medications during critical periods of their care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Gardens At East Mountain, The from 2025-03-07 including all violations, facility responses, and corrective action plans.
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