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F0755
D

Failure to Administer Medications Timely per Physician Orders

Green Bay, Wisconsin Survey Completed on 11-18-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when a resident's medications were not administered in accordance with physician orders and facility policy. The facility's policy requires medications to be administered within one hour of the prescribed time unless otherwise specified. Record review and staff interviews revealed that a resident, who had diagnoses including osteomyelitis, epilepsy, peripheral vascular disease, depression, and osteoarthritis, experienced multiple late administrations of both morning and evening medications. The resident, who was cognitively intact and their own decision maker, reported to the surveyor that their medications, including antiepileptic drugs, were late most days and specifically had not been received by the expected time on the day of the survey. Review of the Medication Administration Record (MAR) showed that the resident's scheduled 8:00 AM medications were administered late on at least seven occasions, with administration times ranging from 9:10 AM to 10:06 AM. Additionally, an evening medication scheduled for 8:00 PM was administered at 11:04 PM on one occasion. Staff interviews confirmed that the nurse was running late with the medication pass and that the resident had expressed concerns about the timeliness of medication administration. The Nursing Home Administrator also acknowledged the facility's policy regarding the one-hour window for medication administration.

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