F0755

D

Failure to Ensure Availability and Administration of Ordered Medications

Lincolnshire, Illinois Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

The facility failed to provide pharmaceutical services and administer medications as ordered for multiple residents when medications were unavailable or not obtained in a timely manner. One resident had an order for Muro 128 ophthalmic ointment to be instilled in the right eye twice daily beginning in early December, but the January and February MARs show multiple missed doses with administration notes stating the medication was not available. A registered nurse reported that during her two weeks at the facility the ointment was never available until recently, that she had called the pharmacy but it never arrived, and that she signed the medication as administered despite not having it because the resident’s mother had a supply. The same resident also had an order for dextromethorphan for cough, with the MAR showing missed doses and notes indicating the medication was not available.

Another resident returned from the emergency room with new orders, including a compounded “Magic Mouthwash” for pain control after biting her tongue and having blood in her mouth. The MAR shows that this resident did not receive several ordered doses, and the pharmacy proof of delivery list indicates the mouthwash was never delivered. A nurse practitioner confirmed that the mouthwash was ordered for pain control and did not believe the resident ever received it. A third resident, who was ordered prazosin 2 mg at bedtime for dreams, missed several doses on the January and February MARs, with order-administration notes stating the medication was on order. The DON stated that all medications should be administered as ordered, that medications should be reordered when there is a 2–3 day supply remaining, and that residents should not have to go without their ordered medications, consistent with the facility’s medication administration policy.