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F0684
E

Medication Administration Policy and Timing Deficiencies

Palos Heights, Illinois Survey Completed on 09-18-2025

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

The facility failed to follow its own medication administration policies and regulatory requirements for several residents. Staff were observed dispensing a different medication (Guaifenesin) than what was prescribed (Guaifenesin-DM) for a resident with a physician order for cough/congestion, as the prescribed medication was not available in the facility. The nurse confirmed that the correct medication was not in stock and the physician was later contacted to change the order, but the resident did not receive the prescribed medication as ordered. Additionally, staff were not aware of the requirement to notify residents when prescribed medications were not administered. Further deficiencies were observed in the timing of medication administration. Staff, including an LPN and a nurse supervisor, demonstrated confusion about the regulatory window for medication administration, with some medications being administered outside the required one-hour window before or after the scheduled time. Electronic Medication Administration Records (EMAR) showed that some residents had not received their scheduled medications on time, and residents were not informed when medications were missed. The facility's policies state that medications should be administered according to the prescriber's written orders and within the specified time frame, and that medications supplied for one resident should never be given to another. These procedures were not consistently followed.

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